Text content and reflective exercises were added to summarize key points and complement the lived experience content with material from relevant therapeutic approaches (e.g., on implementing coping strategies, on changing health behavior, on identifying personal values).

#### Website Design

The design of the site was informed by published guidelines for website development for severe mental illness designed to minimize the impact of difficulties in thinking and memory (25), combined with input from the consultation process, and consideration of how the site could be designed in a way that reinforced recovery. The site was optimized for tablet computer and mobile phone use. Navigation was simplified by organizing content in a minimal number of levels (topic, subtopic), making use of touchscreen scrolling to reduce the required number of page loads and having a single constant menu button. Links between pages were clearly labeled, pages were designed to have minimal distractions, and content was developed to be simple, clear, and logically organized. Key design principles derived from the consultations were (a) simplicity of layout and navigation, (b) flexibility in use (e.g., material can be completed in any order), (c) interactivity, (d) catering to different learning styles and preferences by presenting content in multiple ways, (e) access to any information entered being controlled by the consumer, and (f) promoting a positive emotional experience while engaging with the website (24). Consideration of how recovery processes could be facilitated by the design and features of the site included the following: (a) promoting connectedness by allowing users to comment on material and contribute to a user forum on the site and allowing users to share content with workers, family members, and others; (b) promoting the person taking ownership of their identity by allowing personalization of user profiles and customization of content; and (c) promoting empowerment and responsibility in self-management by the ability to track parameters such as sleep and mood and to set and view goals developed from the material.

The site is accessible only by creation of an account, which enables the user to enter information in reflective exercises, charts, and task lists and to select a username and avatar for posting public comments and using the forum. Forums and comment feeds are monitored by the research team to assess risk of harm to participants, and participants are also able to report any offensive comments for moderator review. Example screenshots are shown in **Figure 2**.

#### Pilot Study

#### Design

To examine feasibility and proof-of-concept of using this tool within service delivery, a pilot study was conducted in the form of a single-arm trial of a mental health worker-facilitated intervention using the SMART website on a tablet computer with participants. All participants received the intervention in addition to treatment as usual during a 3-month delivery window. Assessments were completed at baseline and at 3 months. The project was conducted in accordance with the Declaration of Helsinki, and was approved by the Human Research Ethics Committees at The Alfred (study no. 139-14), St Vincent's Hospital Melbourne (study no. 041.14) and Melbourne Health (study no. 2014.087). All participants gave full informed consent prior to commencement.

#### Participants

Participants were recruited through a combination of mail-outs of consumers, clinician referral at community mental health services, and presentation to consumers at residential services in metropolitan Melbourne. Inclusion criteria were: (a) aged 18–65 years; (b) diagnosis of a psychotic disorder (schizophreniarelated disorder or bipolar disorder or major depressive disorder with the presence of a severe episode with psychotic features within the past 2 years), confirmed using the Structured Clinical Interview for DSM-IV-TR Axis I Disorders [SCID; (26)]; (c) sufficient fluency in English to make use of the resources; (d) overall intellectual functioning within normal limits, having an estimated IQ over 70 based on the Wechsler Test of Adult Reading [WTAR; (27)]; (e) access to Internet at home or *via* smartphone. Exclusion criteria were (f) organic psychosis; and (g) change in antipsychotic medication, in-patient admission,

or the commencement or completion of formal psychological therapy within the preceding 2 months.

#### Procedures

A research assistant met with potential participants to obtain informed consent and complete baseline assessments, including the SCID, WTAR, and first administration of outcome measures. Eligible consenting participants were then provided with a time for their appointment with one of the two facilitators, and went on to complete the eight session intervention. The postintervention assessment was scheduled for 3 months following the baseline assessment, to allow time for missed sessions. The post-intervention assessment also included a treatment evaluation questionnaire. Following this assessment, participants were also contacted by telephone by the project manager to obtain feedback on the site to refine content, during which they were also asked questions about their experience of the intervention more broadly.

#### Intervention

The intervention consisted of eight 50-min face-to-face sessions with an experienced mental health support worker (facilitator), using a tablet computer from which the SMART website was accessed. Participants were assigned to one of two trained facilitators, seconded from the community mental health support sector, and attended sessions at weekly to fortnightly intervals within a window of 3 months, in addition to the participant's routine treatment. An account for the participant to use the website was set up during the first intervention session, and they were shown how to access it to facilitate use outside sessions.

Sessions involved the collaborative selection of content from the seven themes on the site, followed by shared viewing and discussion of website material. Discussions included reflecting on the website content as applicable to the participant's own recovery, considering changes participants may wish to enact based on these reflections, and setting goals for the upcoming week. Facilitators encouraged participants to use the website between sessions, complete reflective exercises, and/or make public posts about the content, if willing.

#### Feasibility and Acceptability

Feasibility and acceptability were indexed by the following:

6. Acceptability in terms of positive versus negative emotional impact of using the site, assessed by the item "Overall, did the website make you feel better, or worse, or no different?" in the post-intervention questionnaire.

#### Outcome Measures

The following measures were completed pre- and post-intervention to provide a preliminary assessment of the outcome.

#### *Personal Recovery*

Personal recovery was the primary outcome. The Questionnaire for the Process of Recovery [QPR; (28)], a 22-item self-report measure developed in conjunction with mental health service users to assess personal recovery. The QPR has good psychometric properties (29) and was used because of its strong alignment with the CHIME framework (30). However, because it was a relatively new measure for which sensitivity to intervention effects was unknown, we also included total score on the more established 41-item Recovery Assessment Scale (31) as a second measure of personal recovery.

#### *Recovery dimensions*

Hope was measured using total score on the Schizophrenia Hope Scale (32), a 9-item questionnaire assessing optimism and hope for the future, rated on 3-point items (*disagree*, *agree*, *strongly agree*). Social connectedness was measured using total score on the Friendship Scale (33), comprising six 5-point (*not at all* to *almost always*) items.

#### *Psychotic Symptoms*

The interviewer-rated Positive and Negative Syndrome Scale [PANSS; (34)] was used to assess the severity of psychotic symptoms and their impact on behavior and functioning. The two research assistants were trained in the standardized administration of the PANSS. In addition, the Subjective Experiences of Psychosis Scale (35) was used to assess the subjective impact of psychotic symptoms in participants reporting ongoing positive symptoms at baseline. This is a 29-item questionnaire on which participants rate the positive and negative impact of their symptoms on aspects of their feelings and behavior, such as "hope for the future" and "ability to socialize." Subjective impact is rated on a 5-point scale from *not at all* to *very much* in the past week. The negative impact subscale score was used in analyses.

#### *Emotional Symptoms*

The 21-item Depression Anxiety Stress Scale [DASS-21; (36)] total score and its associated subscales were used to assess emotional symptoms. Participants reported on their experience of symptoms related to depression, anxiety, and stress in the past week, on a 4-point scale from *did not apply to me at all* to *applied to me very much or most of the time*.

#### *Quality of Life*

Total score on the Assessment of Quality of Life-8 Dimension [AQoL-8D; (37)] was used to assess health-related quality of life. This 35-item questionnaire encompasses eight dimensions of physical and psychosocial health, with lower scores indicating fewer issues related to subjective quality of life in the past week.

#### Process Measures

It was hypothesised that the lived experience content of the intervention would influence outcome by increasing self-efficacy for positive recovery, and by reducing the extent to which mental illness is viewed in negative stigmatized terms. The proposed mechanism was assessed by the following measures.

#### *Self-Stigma*

Self-stigma was used as an index of negative views of illness, measured using the 29-item Internalized Stigma of Mental Illness Scale [ISMI; (38)] which includes subscales of alienation, stereotype endorsement, discrimination experience, social withdrawal, and stigma resistance. Items are rated on a 4-point scale from *strongly disagree* to *strongly agree*.

#### *Self-Efficacy*

Self-efficacy was measured using total score on the Generalized Self-Efficacy Scale (39), a 10-item questionnaire rated on a 4-point scale from *not at all true* to *exactly true*.

Additionally, qualitative feedback on experiences of using the lived experience videos was collated from the post-intervention interview. Use of antipsychotic medication was also recorded at baseline and 3 months as a potential confound.

#### Treatment Evaluation

Subjective perceptions of the helpfulness or otherwise of the intervention were assessed by the item "Do you feel that using the website made the impact of your mental health problems better, or worse, or no different?" based on an item used by our group in previous trials with this population (40, 41). This was rated on a 5-point scale from *much worse* to *much better*. Additionally, 11 5-point Likert items were developed to assess whether participants endorsed changes having occurred in relation to material covered on the site (e.g., "I feel more hopeful about my recovery"). Questions were also included in the qualitative phone interview to gather feedback on use of the site during sessions with a worker, and on specific site elements including the videos.

#### Statistical Analyses

In this pilot study, the emphasis was on examining acceptability and feasibility, as well as allowing a preliminary estimate of treatment effects, rather than using inferential statistics to hypothesis–test specific outcomes. Correspondingly, effect sizes and confidence intervals were calculated for the mean pre- to post-intervention change score. Standardized effect sizes were calculated by dividing the mean change by the average SD of pre and post-intervention scores or, if variances were unequal, the baseline SD (42). A series of paired *t*-tests was also conducted to indicate where two-tailed significances fell within *p* < 0.05. Complete data were available for all participants.

#### RESULTS

Twelve potential participants were recruited for the study. Two of these were excluded at baseline: one due to a recent medication change and the other due to participation in another research project. Ten participants completed the baseline assessment (nine males; mean age 42.6 years, SD 12.47, range 23–62 years; six single, four divorced). Nine had a diagnosis of schizophrenia, and one of schizoaffective disorder. None worked full time; two were in paid part-time work and one in volunteer work. All were receiving antipsychotic medication. At baseline, seven participants reported using the Internet at least daily, one once per week, and two "rarely or never." Half of the participants reported that they "rarely or never" used the Internet to access information about mental health.

#### Feasibility and Acceptability In-Session Use

The website was used in 76 of 80 sessions that were attended. Of the remainder, two were initial sessions spent assisting participants setting up email to use the site, and one was a final session consolidating the program material without use of the site. There was only one session in which the support worker was not able to use the site with the participant. Session notes indicated that the participant's engagement had been threatened in a previous appointment, when the facilitator misunderstood something that the participant was discussing, and subsequently directed them to an unrelated topic on the site. The session was spent having a broader discussion of recovery without use of the site to reengage the participant, and the participant and the worker went on to use the site further in their remaining sessions.

Qualitative feedback on the use of the site in-session is collated in **Table 1**. Responses suggested that the process of integrating the website as a tool in sessions functioned well. Some participants expressed that they would have been less engaged or unable to use the site independently without the facilitator sessions, and a number of participants commented that the site facilitated discussion with the worker.

#### Between-Session Use

Six of the 10 participants independently logged on to the site outside of sessions, with a median of 4.5 log-ons among those who did this (range 1–14). Among these six participants was one of the participants who "rarely or never" used the Internet at baseline, the remainder being daily users. Six participants posted public comments on the site, with a median of two posts among those who posted (range 1–20 posts).

#### Drop Out and Satisfaction

All 10 participants attended the full course of eight intervention sessions, and all 10 participants said during the post-intervention interview that they would recommend the site to others.

#### Emotional Impact of Site Use

No participants indicated a negative emotional impact of use of the site, with all 10 reporting a positive effect of using the site on how they felt (responses *better* or *much better*).

#### Table 1 | Participants' feedback about using the site together with a worker.

P1. I think the technology was, it was a guide, it kept our discussion going in a direction that we wanted it to go in. And it would raise the topic or it would raise the, the next discussion, so it was guiding what we were going through. But we did do a lot of talking with [the facilitator] and I felt the two worked together really, really well … perfect. I did say to [her] though that I felt that the facilitator was needed. I felt that while I was at home I didn't have, there was no accountability. I didn't have anyone looking over my shoulder telling me "You must do that" and "you must go to the website", "you must do a module or whatever", there was no accountability. But with a facilitator where I'm going to see [her], you know, within a few days, and we were going to discuss this, then there was accountability, I had to get some things done.

P2. Yeah it was very easy and [the facilitator] explained everything well to me, yeah. And ah, even, I think even just without her I think I could have gone through it myself it would have been quite easy … yeah, yeah. There was some bits in there, um some bits that were a bit difficult to understand, yeah. Not much, but there were two or three parts that she helped me with … And not only that, ah, having someone there as a support to go through every single one of them, I think that very helpful … I guess the SMART, the website goes into more detail into aspects of my life.

P3. We were able to acknowledge and cover things in more depth than I would have by myself.

P4. It's fine, so the iPad was useful, but I'm not the type of person to sort of sit down and do that sort of stuff. I'm more of an interactive person with whoever I'm talking to. … I enjoyed talking to her more than using the iPad.

P5. I thought it worked well. Yeah. … Like with the iPad, I thought that, what do you want to discuss today? There's always, it was more, this program, it was more about what you had to say and what you thought of situations instead of, instead of feeling intimidated when you go in to other ways to see a worker or feeling like oh what are going to say and then feeling like intimidated. But in this case I didn't feel intimidated, I knew [the facilitator] well, and I thought that she did a great job just explaining everything to me, patience, and all of it.

P6. I thought it was really easy. Really easy. Smooth and, ah yeah, just a pleasant experience … . if it was just sort paper and pencils, it sort of got a bit dull after a while. … but the iPad and the website made it quite colourful and a bit more interesting.

P7. Well I didn't use it, I know it's going to sound funny, but we didn't use it much, just for me to get to where I'd written it at home and then read it out to her, "oh this is what I've written and this is what I've written, and this is what I've done," and then discuss it because I can't type properly on an iPad and I like to type really fast and you know, and be able to check my spelling and everything so I just did it at home., and I was happy. … I'd just log on and do some stuff at home and then in the sessions they were really just to go over what I'd done at home and what had come up and so she was sort of acting therapist, poor [facilitator]. … No with the iPad, because I got to share all, everything I'd written, and we'd talk about what I wrote. Talk about subjects and say, "What subject should I do next?" and "What's that involve?" And, "Maybe this one would work," and then I'd say, "Can you do a print out of the PDF, and yadayadayada." A lot more involved than just seeing a therapist, you know what I mean.

P8. [Without the website] we wouldn't have had nearly as much to talk about. And then I would have been more stuck for words I think. I wouldn't have been able to talk about all the issues that we had discussed about the website so it would have been a bit more difficult I think.

P9. It was just really good. A good experience with [the facilitator] and the iPad.

P10. I would've really hated it if I did it by myself, because I probably wouldn't have got there anyway, I mean anywhere, but that's why I thought, I didn't mind it so much, because um people like [the facilitator] were just such a good guide. But something like, with computers, I couldn't do it myself, even though it seemed pretty simple, once [the facilitator] was showing me what to do, I just said, I really would hate to do it by myself …

#### Outcomes

Estimated effect sizes on the outcome measures are presented in **Table 2**. On the primary outcome of personal recovery, an estimated medium effect size was observed on the QPR, which in spite of the small sample size was statistically significant. A similar magnitude effect was observed on the RAS as a second measure of recovery (also statistically significant). Among other outcomes, medium effects were estimated for the subjective negative impact of psychosis symptoms, emotional symptoms on the DASS, and hope, but there was a negligible effect on social connectedness. A small effect size was estimated on the PANSS and the AQoL-8D.

Among process measures, a small to medium effect was estimated on self-stigma, but negligible effects were evident on self-efficacy. Examination of subscales of the ISMI self-stigma measure suggested that the strongest effects were in reducing perceived alienation with an estimated moderate to large effect size (statistically significant), while the estimated effect on other domains, such as negative stereotype endorsement, were negligible. Two participants had increases and three had decreases in antipsychotic medication dose during the trial, but changes on the personal recovery measures were not correlated with changes in chlorpromazine-equivalent dose.

In response to the question "Do you feel that using the website made the impact of your mental health problems better, or worse, or no different?" eight participants reported that their mental health was better or much better, with the remaining two reporting it was no different. Agreement was also high on all items of the treatment evaluation questionnaire (**Table 3**). Specific feedback on the lived experience videos is collated in **Table 4**.

#### DISCUSSION

This study examined the feasibility of an intervention targeting personal recovery in psychosis, a domain for which intervention development is a priority. It involved the novel combination of lived experience-based content on recovery, presentation *via* a digital medium, and delivery integrated with face-to-face mental health sessions. Overall, it appeared feasible to deliver an intervention in this way, and there were promising findings on the primary outcome of personal recovery.

#### Table 2 | Estimated effects on outcome measures.

*N* = *10, except for SEPS negative impact (N* = *7).*

*QPR, Questionnaire for the Process of Recovery; RAS, Recovery Assessment Scale; SHS, Schizophrenia Hope Scale; PANSS, Positive and Negative Syndrome Scale; SEPS,*

*Subjective Experience of Psychosis Scale; DASS-21, Depression Anxiety Stress Scale 21; AQoL-8D, Assessment of Quality of Life-8 dimension; GSES, Generalized Self-Efficacy Scale; ISMI, Internalized Stigma of Mental Illness.*

#### Table 3 | Participant responses on the treatment evaluation questionnaire.

Our attempts to develop the main content of the site by using a process of editing together various lived experience interviews showed this to be a feasible approach. We used 11 lived experience speakers to provide diversity in age, gender, ethnicity, and sexuality within the group, which was sufficient to produce material for all topics. Not all content within the topics was covered in this way, but complementary scripted videos from experts and text material was used to complete an effective website in which the dominant content was explicitly authored by peers. While many online interventions include "client perspective" videos to illustrate other material [e.g., Ref. (43, 44)], this is the first online intervention, we are aware of, that has an explicit focus on lived experience material as the main vehicle for change.

Use of the site in-session appeared to be feasible and acceptable to participants. The website was used regularly in-session, no participants dropped out, and participants gave generally positive feedback about how the use of the site integrated with face-to-face work. It appeared from participant feedback that many would have found it harder to use or maintain engagement with the site had it not been integrated with sessions with the facilitator. The feedback is consistent with the broader digital mental health literature, where therapist-assisted interventions tend to be engaged with for longer than self-guided interventions (45). However, lower levels of use of digital technology (46) and higher rates of disability among persons with severe mental illness suggest some people may be more reliant upon support to utilize online materials. A blended approach offers a means of capitalizing

#### Table 4 | Participants' feedback about lived experience videos.

P1. I enjoyed, I guess, what's the name of the word, the reinforcement, or, seeing somebody else going through the same situation with the same feelings, somebody I could relate to, I found, it was something I hadn't been through before and, and that made me feel good, that felt great and a lot more at ease from watching the video. The video also … what I did try and do once or twice was to answer questions without watching the video and then, going back watching the video, realised that the video was actually opening up the scope, it was actually scoping out the area ahead of what the questions were going to be like.

P2. The fact that others are sharing their own experience. … Yeah, and I look at the video and even though I was hospitalised before, when I come out – it's been a while since I came out – I forget that ah, I'm not alone. Yeah.

P3. Really enlightening. Made me feel like I am not alone.

P4. Well … relate to people … what they're saying: this is what happened to me and how I got over it, and what I did. Yeah.

P5. I like the fact that everyone's so different, it's so, like they all have different, and they're all unique, and they all had good things to say. Like what I mean by good is, you know, relevant to people with like, yeah. I didn't feel so alone. So that was a good thing. … I just felt like I could relate to someone. I wasn't so alone.

P6. There were obviously the different individuals who explained their scenario and talked about each topic in the video, and then said what that topics means to them, and how certain questions around the topic are answered, and it was all good, it was all insightful. … Yes, the videos were really good, they were organised, they were structured, quite informative, honest, and um yeah, so like lots of multi-perspectives on topics – yeah, that was good.

P7. Because I could just sit there and watch a whole half hour of them talking and get so inspired, and so moved, you know. … it makes you realise you're not alone, and that you're not some frumpy sort of, the bad image of mental illness: not washed, not clothed well, smells bad, can't coherently keep a sentence together, looks off into the distance, is aggressive or threatening or sullen. You know what I mean?

P8. I could relate to a lot of peoples' stories, and they had a similar experience to mine, so I thought that was good. And then I answered a few questions and sent a few comments to [the facilitator] and that sort of thing. So yeah I just, I gained more insight into my condition I think. I've always had a lot of insight, but just hearing other peoples' experiences; when you think you've got your own mind made up about your illness and you won't listen to anybody about your illness, and you need to think "oh okay," you think you're right, but there are a lot of other people who have varying symptoms, and it was just good to hear other peoples' opinions and impressions of their own diagnosis, and that sort of thing; what they do to tackle their problems. So it was good.

P9. I can relate to some of the things they were talking about in my own life, and it just makes me more aware and more determined to overcome the obstacles that I've been facing.

P10. They had people talking about how to handle stress, and I put my feet in their shoes and sort of could understand, you know, um where those people were coming from, their experiences.

on the scalability of digital interventions to deliver quality structured interventions, while bearing in mind the barriers to independent Internet use experienced by this group. Indeed, although most participants used the site between sessions as well, which was encouraged, not all of the participants in this pilot did so, suggesting that a significant proportion of people in this population would be reliant on in-session use. Indeed, it should also be noted that most of our sample were daily Internet users at baseline, so their existing levels of computer use were higher than average for this population (46). Given our vision for the website as a vehicle to facilitate discussion between the consumer and worker about recovery, the modest between-session use was not problematic. A number of participants' responses confirmed that use of the site did help them discuss issues which otherwise might not have been raised or would have been difficult to raise.

Video-based tools may have benefits beyond the present aim of facilitating discussions about recovery: future research could investigate whether patient–worker interactions around embarrassing or sensitive topics (e.g., discussing ambivalence about medication) are supported by tools of this kind. The technology may have broader applications in practice, such as in promoting supported decision making [e.g., Ref. (47)], or as a tool for formal psychological therapies.

As a preliminary proof-of-concept study with a small sample, analysis of outcome was not designed to hypothesis–test efficacy, but to establish whether estimated effects were in a range suggesting full scale trialing to be worthwhile. While we cannot be certain that other ongoing interventions had no impact on outcomes, results were promising, with a moderate effect size being estimated on both measures of recovery that were used. Feedback from participants was also consistent with the intervention having a beneficial impact upon recovery, and participant feedback additionally identified no negative effects. The estimated effect size on recovery is similar to effects observed for other psychosocial interventions for persisting psychosis (48). Together, these findings suggest value in conducting a larger-scale controlled trial of this intervention (49).

#### AUTHOR CONTRIBUTIONS

All authors participated in the development and pilot of the digital intervention. NT, FF, NL, JF, EL, CN, SF, LS, and GM designed the website and developed its content. NT, JF, FF, RF, and TS developed the therapist intervention protocol. NT, K-AV, and FF conducted analyses and prepared the manuscript. All the authors read and approved the final manuscript.

#### ACKNOWLEDGMENTS

The authors gratefully acknowledge the contributions of the video contributors; Rybazoid (video production); Fidget Friend (software development); Alfred Health, Mind Australia, NorthWestern Mental Health, St Vincent's Hospital Melbourne, Tandem, VICSERV, the Victorian Mental Illness Awareness Council, Wellways Australia (Mental Illness Fellowship); Katrina Lindblom, Friederike Wahl, Robert Shaw, Claire Young, Jo-Anne Abbott, Alex Lopez Lorca, Sonja Pedel, Maheswaree Kissoon Curumsing, and members of the focus and reference groups.

#### REFERENCES

#### FUNDING

This study was funded by the State Government of Victoria Department of Health Mental Illness Research Fund (MIRF33). The funder had no role in the design of the study or reporting of results.

Robertson S, et al., editors. *Proceedings of the 24th TheMHS Mental Health Services Conference 2014*. Balmain, NSW: TheMHS (2015a).

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Copyright © 2016 Thomas, Farhall, Foley, Leitan, Villagonzalo, Ladd, Nunan, Farnan, Frankish, Smark, Rossell, Sterling, Murray, Castle and Kyrios. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# What Role Can Avatars Play in e-Mental Health Interventions? Exploring New Models of Client–Therapist Interaction

*Imogen C. Rehm1 , Emily Foenander1 , Klaire Wallace1 , Jo-Anne M. Abbott1 , Michael Kyrios2 and Neil Thomas1,3\**

*1National eTherapy Centre, Centre for Mental Health, Swinburne University of Technology, Melbourne, VIC, Australia, 2Research School of Psychology, College of Medicine, Biology and Environment, Australian National University, Canberra, ACT, Australia, 3Monash Alfred Psychiatry Research Centre, Monash University Central Clinical School and The Alfred, Melbourne, VIC, Australia*

#### *Edited by:*

*Jérôme Favrod, University of Applied Sciences and Arts of Western Switzerland, Switzerland*

#### *Reviewed by:*

*Andrew Molodynski, Oxford University, UK Gaudelus Baptiste, Centre Hospitalier Le Vinatier, France*

> *\*Correspondence: Neil Thomas<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Public Mental Health, a section of the journal Frontiers in Psychiatry*

*Received: 20 September 2016 Accepted: 03 November 2016 Published: 18 November 2016*

#### *Citation:*

*Rehm IC, Foenander E, Wallace K, Abbott JM, Kyrios M and Thomas N (2016) What Role Can Avatars Play in e-Mental Health Interventions? Exploring New Models of Client–Therapist Interaction. Front. Psychiatry 7:186. doi: 10.3389/fpsyt.2016.00186*

In the burgeoning field of e-mental health interventions, avatars are increasingly being utilized to facilitate online communication between clients and therapists, and among peers. Avatars are digital self-representations, which enable individuals to interact with each other in computer-based virtual environments. In this narrative review, we examine the psychotherapeutic applications of avatars that have been investigated and trialed to date. Five key applications were identified (1) in the formation of online peer support communities; (2) replicating traditional modes of psychotherapy by using avatars as a vehicle to communicate within a wholly virtual environment; (3) using avatar technology to facilitate or augment face-to-face treatment; (4) as part of serious games; and (5) communication with an autonomous virtual therapist. Across these applications, avatars appeared to serve several functions conducive to treatment engagement by (1) facilitating the development of a virtual therapeutic alliance; (2) reducing communication barriers; (3) promoting treatment-seeking through anonymity; (4) promoting expression and exploration of client identity; and (5) enabling therapists to control and manipulate treatment stimuli. Further research into the feasibility and ethical implementation of avatar-based psychotherapies is required.

Keywords: avatars, virtual environments, virtual reality, e-mental health, digital mental health, human–computer interaction, computer-mediated communication

#### INTRODUCTION

In online virtual environments, multiple remotely located users can synchronously communicate and interact with each other *via* an avatar – a digital character that the user can customize to represent his/ her identity. In their seminal 2008 paper, Gorini et al. (1) proposed two key applications of avatars in multiuser, computer-based, three-dimensional virtual worlds, such as *Second Life*, which could potentially transform the delivery of online interventions for mental health problems (i.e., e-mental health interventions). These included (1) an alternative form of technology (i.e., other than head-mounted virtual reality devices) to deliver exposure-based therapy for anxiety disorders and substance-abuse problems and (2) facilitation of online peer support communities. Studies since 2008 have proposed several further applications of avatars in the delivery of e-mental health interventions. For instance, head-mounted virtual reality devices that immerse clients into computer-generated interactions with avatars are increasingly being utilized to treat anxiety disorders (2) and persecutory delusions (3). Indeed, immersive virtual reality technology has previously been reviewed for its significant potential in psychiatric applications (4, 5). In this narrative review, we consider the psychotherapeutic applications of computer-based and online avatar technology; specifically, the ways in which avatars have been used to replace or augment traditional models of client–therapist interaction and communication. We additionally synthesize the functions that avatars can serve in such applications and consider the advantages and challenges of implementing this novel technology within e-mental health interventions.

#### APPLICATIONS OF AVATARS IN e-MENTAL HEALTH: AN OVERVIEW

#### Online Peer Support Communities

The potential to foster cohesive social networks is cited as a strength of virtual worlds in which users can interact with each other by adopting personalized avatars (1). Most attention has focused on the program Second Life, where users can create realistic-looking human avatars that they can use to manipulate stimuli within the virtual environment and remotely interact with other users – also represented as avatars – *via* text and/or audio.

In 2008, there were 68 health-related activities on Second Life, 20% of which were intended primarily for peer support (6). Many peer communities focused on sensitive topics (e.g., sexual health, addictions) or were organized for and by groups of people who are vulnerable to marginalization and discrimination in "real life" (e.g., people with disabilities). The popularity of Second Life peer support communities, and additional health-related activities (e.g., health promotion and education), may result from users' ability to collaborate, interact, and consult with other avatars in real time while maintaining their anonymity (6). By 2013, only 24 health-related Second Life sites were still active, many of which were absent of other users when researchers entered the virtual host spaces (7). Thus, user anonymity may have actually minimized investment in building long-term relationships.

#### Avatar Use to Replicate Traditional Psychotherapy Models in Online Virtual Environments

The Second Life platform has strong potential to replicate models of individual and group-based treatments, but conducted entirely online, with both client and therapist interacting with each other in a virtual environment. To date, this model has been trialed in two uncontrolled studies using individual (8) and group (9) formats.

Yuen et al. (8) conducted a manualized, acceptance-based behavioral treatment for adults with social anxiety disorder, delivered entirely *via* Second Life. Participants (*n* = 14) and therapists (*n* = 3) met in a private, secure virtual therapy room for a 1-h individual treatment session each week for 12 weeks. During role-playing exposure exercises, sessions occurred in other virtual spaces relevant to the exposure scenario (e.g., giving a presentation in a virtual conference room), with confederate therapists facilitating each exercise by adopting pre-made avatars with diverse physical characteristics (e.g., age, gender, ethnicity). Intention-to-treat analyses for a range of mood, psychosocial, and social anxiety measures indicated large posttreatment and 12-week follow-up effect sizes. Future research comparing the intervention to a control condition is required.

Also delivered in Second Life, Hoch et al. (9) developed an 8-week relaxation and mindfulness group, with sessions delivered twice-weekly to groups of up to 10 participants. The first session of each week involved teaching the participants specific relaxation strategies. In the second session, participants met in a virtual teaching space designed to look peaceful (e.g., a virtual forest), where they were asked to review their practice of these strategies. Overall, mental health symptoms measured by the Symptom Checklist 90 decreased from pretreatment to posttreatment, although changes were not statistically significant. Future research may need to use gold-standard measures of specific psychopathology symptoms, which may be more sensitive to changes. However, participants reported that they appreciated the convenience of being able to participate remotely in a virtual group program and also commented that the anonymity of participation made the intervention material more approachable.

#### Avatar-Assisted Face-to-Face Therapies

Several studies have utilized various forms of avatar technology to facilitate or augment treatments that are delivered with the face-to-face support of a therapist. Two models of these avatarassisted therapies have been implemented, which are as follows: (1) applications that require the client to "embody" or represent themselves as an avatar in order to participate in the therapy and (2) applications that do not require the client to embody an avatar, but rather, require the client to *interact with another avatar*, be it the therapist or an "other."

#### Embodied Use of Avatars by the Client

Using Second Life, Kandalaft et al. (10) delivered a manualized social skills training program to eight young adults with high-functioning autism spectrum disorder. Ten sessions were completed over 5 weeks, during which the therapist physically sat alongside and coached the participant through virtual role-playing scenarios. During each session, the therapist – represented as an avatar – directed participants to various virtual spaces (e.g., cafes, parks, shops) where they met with a confederate clinician – also represented as an avatar – to practice social interactions in diverse role-playing situations (e.g., attending a job interview). Clinicianadministered neurocognitive measures of verbal and non-verbal emotional recognition significantly improved from pre- to postprogram, suggesting that the program may improve elements of social communication typically impaired in people with autism.

Using a different commercially available avatar platform (*ProReal*), van Rijn et al. (11) used avatar-mediated communication as a component of face-to-face group therapy in a prison setting. Unlike Second Life avatars, ProReal avatars appear as androgynous, featureless human forms, which users can manipulate in terms of color, size, and expressive gestures. ProReal avatars can also be given virtual props to facilitate symbolic emotional expression, such that participants could use the avatars to explore and communicate their emotions to other group members. Group therapy sessions were 90-min long, ran for 6 weeks, and were facilitated by a counselor. Distress ratings measured by the CORE-10 did reduce from pretreatment to posttreatment, although not statistically significantly. Qualitative feedback suggested that the avatars supported participants to express emotions that were difficult to communicate verbally, and to develop empathy for other group members.

#### Avatar-Mediated and Augmented Therapeutic Interactions

Avatar software can offer clients unique scope to address or confront their symptoms, within a safe and controlled environment, with the support of a therapist. Leff et al. (12) utilized this technology as part of a novel treatment for persecutory auditory hallucinations, with participants (*n* = 26) asked to create an animated avatar face of the entity that they believed was talking to them. In conjunction with voice transformation software to distort the therapist's speech, the therapist used the avatar to role play the person's auditory hallucination during exercises designed to support the person responding to their voice more adaptively. Highly promising results were reported in a pilot trial (12), with reductions in hallucination severity relative to wait-list controls, and some participants reporting a remission of their voices. These findings are currently being examined in a full sale randomized controlled trial (RCT) (13).

The value of avatar technology for learning and practice of new social skills has been recognized by numerous authors (5, 14–16). Both Rus-Calafell et al. (14) and Peyroux and Franck (15, 16) have used avatars to simulate social situations as part of social cognitive remediation programs for people with psychotic disorders. In the twice-weekly, 8-week *Soskitrain* program (14), participants (*n* = 12) practiced social skills with a variety of expressive avatar characters in different situational environments. Therapists could control the avatar's behaviors according to participant responses to promote scaffolded learning and stop the interaction for therapeutic discussion. In an uncontrolled pilot trial of the program, Rus-Calafell et al. (14) reported significant pretreatment to posttreatment improvements to participants' self-reported negative symptoms, social avoidance, and social functioning. System-recorded facial emotion recognition errors and time spent in avatar-based conversations also improved. Gains were maintained at 4-month follow-up. Using a different avatar-based simulation program (*RC2S*), Peyroux and Franck (16) reported two experimental single-case studies that made significant pretreatment to posttreatment improvements in theory of mind abilities and improved facial emotion recognition, social knowledge, self-esteem, and attributional style. Using RC2S (15, 16), participants learned to analyze the mental state, emotions, and intentions of "Tom," an avatar character, to guide Tom's responses to various social situations. As in Soskitrain, the therapist's role was to provide social skills training and feedback to support participant's interactions with the avatar.

#### Avatars to Participate in "Serious Games"

Many video games require that the player embodies an avatar to interact with other players or to interact with automated non-player characters. In "serious games," such game-like elements are incorporated into computerized psychotherapies to achieve a serious health-related goal (e.g., to reduce depression symptoms) (17). SPARX is an example of a serious game in which the participant, as an avatar, progresses through seven modules of a fantasy-based computerized game (18, 19), which incorporates cognitive–behavioral therapy strategies to treat depression in adolescents. At the commencement of each module, participants meet with an automated guide whose role is akin to a therapist. The guide informs participants of their tasks for each module and how they relate to improving depression. At the end of each module the guide provides a summary of what was learned. SPARX has shown efficacy in two RCTs, and participants have reported high levels of treatment satisfaction and acceptability (18, 20).

Unlike aforementioned avatar-based therapies (8–12), SPARX is an entirely self-guided e-mental health intervention. Participant feedback suggested that the self-guided nature of the program was one of its strengths, as were gaming elements that supported treatment engagement such as a story-like narrative throughout the seven modules, and automated characters that were perceived as being warm and caring (21).

#### Avatars as Autonomous Virtual Therapists

Finally, avatars have been utilized as autonomous virtual therapists – also referred to as embodied communicative/relational agents – to facilitate the clinical interview and assessment process, to provide psychoeducation, or to direct individuals to access alternative psychological services (22–25). In these applications, the client is not required to embody an avatar to interact with the therapeutic agent, as in Second Life (8–10) and SPARX (18–20). Furthermore, the therapeutic agent, which can be represented as a realistic-looking human avatar (22–24) or as a two-dimensional animated character (25), is not controlled by a human clinician. Rather, the avatar is an autonomous agent presented on a computer monitor, which responds to the client's text-based, auditory, and/or sensory input on the basis of artificial intelligence or algorithm.

To investigate user experiences, Rizzo et al. (22) conducted clinical interviews with 91 adults who interacted with an autonomous virtual therapist called "Ellie." Their experiences were compared to 120 participants who interacted with a clinicianoperated version of Ellie and 140 participants who participated in face-to-face clinical interviews. Most participants reported that they were willing and felt comfortable to share information with Ellie (in both autonomous and clinician-operated conditions), which is consistent with other studies that have found participants highly rate the therapeutic alliance with relational agents (25). Ratings of rapport and listening skills were significantly greater for the clinician-operated avatar than the autonomous avatar, and rapport ratings for the clinician-operated avatar exceeded those of face-to-face clinical interviewers. This may indicate the importance of realistic transactional elements in virtual interactions for reducing emotional barriers to client engagement (22); however, this suggestion requires investigation.

Pinto et al. (23, 24) investigated the efficacy of an avatar-based self-management intervention for young adults with depression (Electronic Self-Management Resource Training for Mental Health; eSMART-MH). *Via* laptops, participants accessed a virtual primary health clinic to communicate with simulated avatar health-care professionals. The program was designed to provide young people with training and practice in communicating with health-care professionals about depression, and to learn self-management strategies. An RCT (23) demonstrated that self-reported depression symptoms decreased significantly more for the eSMART-MH group (*n* = 12), when compared to an attentional control group; however, there was no significant change in symptoms from baseline to 12-week follow-up in either group. Participant feedback for future versions of the intervention included greater range of user input and avatar response options, the possibility to receive counseling, and access to the program *via* mobile devices (24).

#### THERAPEUTIC FUNCTIONS AND CHALLENGES OF AVATAR TECHNOLOGY

#### Supporting the Therapeutic Relationship through Virtual Presence

As the reviewed studies demonstrate, several applications have involved both the therapist and client utilizing avatars as a form of virtual embodiment (8–10), which allows both parties to feel a sense of social presence within a remotely accessed online environment. This sense of social presence, and the tendency for people to engage in greater self-disclosure during computermediated communication compared to face-to-face interactions (26), has strong potential to facilitate the development of online therapeutic relationships and may be more important for presentations where shame or stigma are central features. Indeed, feelings of copresence, emotional closeness, and interpersonal trust are equivalent for avatar-, audio-, and video-based modes of communication (27). In line with the contention that avatars can generate social presence in virtual environments, participants in a number of the studies listed above noted that their interactions fostered a sense of genuine rapport (8, 10), even when the real/implied therapist was operated on the basis of automated therapeutic scripts (21, 24) or artificial intelligence (22).

#### Reduction of Communication Barriers

The flexibility to use audio- and/or text-based communication in avatar platforms provides options for clients to choose a communication mode with which they feel most comfortable. For instance, Stendal and Balandin (28) illustrated how text-based communication in Second Life reduced communication barriers for a participant with autism spectrum disorder by reducing the ambiguity of social and emotional cues during his interactions with online peers. The participant reported feeling a sense of security and control that he perceived his disability did not afford him in the "real world," empowering him to develop personally valued online friendships. Relatedly, participants with autism spectrum disorder in Kandalaft et al.'s study (10) suggested that being comfortable with computer-mediated communication supported their confidence to participate in the avatar-simulated social situations. For many individuals with physical, mental, and language impairments, the ability to communicate *via* an online medium of choice and from the perceived safety of one's home is likely to be an advantage of avatar-based technology.

Like other forms of online communication, however, technical difficulties can create new communication barriers that impact on the quality of treatment sessions (e.g., flow, timing) (8), and clients must feel confident to use (or learn to use) the technology in the first instance. Another issue to consider is that the lack of visual cues may reduce a sense of accountability to one's conversational partner, as both parties can engage in other tasks without the other being able to see this occurring. Even for therapists, this can foster a sense of disconnectedness, which itself can inhibit the development of communicational and emotional attunement (29).

#### Anonymity to Promote Treatment-Seeking

Unlike videoconferencing, avatars afford the possibility of anonymous engagement with psychological services. Potentially, this may attract individuals to receive treatment they may otherwise not seek (e.g., due to shame or stigma) by engaging them wholly in an avatar-based e-mental health intervention (29) or by encouraging them to seek face-to-face treatment following an anonymous and positive interaction with an autonomous virtual therapist (22, 24). A case study by Quackenbush and Krasner (29) highlighted how a client who was reluctant to engage in online treatment *via* videoconferencing due to fear of racial discrimination was successfully treated in Second Life, where the client was able to use an avatar and pseudonym that disguised his ethnicity.

Reflecting ethical concerns relating to risk management and client safety, anonymous use of avatar technology has been recommended only for instances in which the client is seeking generic psychoeducation and referral information (22, 30). When ongoing avatar-based psychotherapy services are offered, authentication of the client's identity is advised (30). This can still permit pseudonymity and customization of one's avatar. The psychological impact of a client's "anonymized" avatar on both the client and therapist requires investigation; particularly in light of evidence that altering the visual features of an avatar (e.g., height, attractiveness) can both positively and negatively affect the individual's virtual and "real world" behavior (31).

#### Exploration of Client Identity

A particularly novel component of (embodied) avatar use in online psychotherapeutic interventions is the capacity they provide for clients to express, experiment with, explore, and construct a virtual, visual representation of their identity. In the context of using Second Life for social purposes, three functions of avatars as an expression of the individual's "real world" identity have been identified (32). First, avatars can be utilized as a vehicle for engaging in a virtual world, whereby the individual's representation of their true physical characteristics, and their real name, occupation, interests, etc., were conveyed *via* their avatar. Second, avatars could be utilized to enhance one's real world self by embodying features perceived by the individual as positive; for instance, customizing the avatar to appear more youthful or expressing personality traits the individual normally suppresses. Finally, avatars could be utilized to diversify one's identity by adopting an entirely new identity in the virtual world; for instance, adopting a new name, different gender, creating a new "life story," and visually representing one's avatar in a way that does not reflect one's true physical appearance. Participants reported that regardless of whether they utilized their avatar for self-extension, enhancement, or diversification, experiences within Second Life generalized to positive physical, cognitive, social, or emotional outcomes in the real world. Such identitybased functions could have significant implications for the therapeutic use of avatars.

#### Manipulation and Control of Treatment Stimuli

Finally, the ability for the therapist to control the content of virtual stimuli and intensity of virtual situations as part of behavioral interventions is a key advantage of avatar technology over other forms of computer-mediated communication (1). As with virtual reality exposure therapy conducted through head-mounted display devices, computer-based virtual reality applications can be conducted remotely (8, 9) or within the therapist's office (10–16), thereby offering a safe environment for exposure-based treatments; compared to *in vivo* therapies, sessions utilizing the same exposure stimuli or role-playing scenarios can feasibly and conveniently be repeated as often as needed for the client to learn new skills; and clients may feel a greater sense of control over and safety within virtual settings, which could support treatment adherence. Additionally, computer-based applications are unlikely to induce the nausea and sensory distortions that can be experienced with virtual reality technology (33).

Research is required to determine whether computer-based virtual reality applications can generate an equivalent sense of realistic "presence" as do head-mounted simulation technologies; the assumption being that presence will elicit the level of anxiety required for habituation over the course of exposure therapy (34). The role of presence as a mechanism of behavior change requires greater investigation across all modalities of virtual therapies, as does the level of photorealism required of avatars and virtual environments to induce a sense of being immersed in a therapeutic interaction. This may depend on the needs of the clinical population undergoing treatment. For instance, the high drop-out rate (34.6%) from Leff et al.'s (12) treatment for auditory

#### REFERENCES

hallucinations may have indicated that use of avatars to represent experiences more concretely may have been too confronting for many participants to tolerate.

#### CONCLUSION

The use of avatars in e-mental health interventions represents a nascent area of inquiry. As demonstrated in this review, the psychotherapeutic applications of computer-based and online avatar technologies have been diverse. Several of the studies reviewed in this paper were uncontrolled trials with small sample sizes and framed as pilot investigations of feasibility as opposed to efficacy. The diversity in study aims, methodologies, participant groups, intervention types, outcome measures, technologies, and treatment delivery models prevents a conclusion as to the efficacy of avatars in delivering e-mental health interventions – nor was this the aim of this review. However, this diversity does highlight its significant potential and functionality.

As a flexible and creative platform with which to deliver individual and group therapies, peer support, and as a form of e-mental health augmentative intervention, avatar technology offers significant potential to engage a broad range of clients in need of psychological support who may otherwise be unable or unwilling to participate in traditional treatment models. In particular, avatars may foster the development of a strong virtual therapeutic alliance; overcome communication barriers experienced by individuals with various disabilities and mental disorders; offer an anonymized means of seeking treatment; support clients to explore and extend their identity; and provide therapists with greater control over treatment stimuli that involve an element of exposure or skills training. Nevertheless, there appear to be many challenges to the ethical and feasible implementation of avatar-based e-mental health interventions. In light of advancing portable technologies, such as smart phones and tablet devices, it will be interesting to observe how the models of avatar-based e-mental health interventions will further diversify and enable greater access to engaging interventions. Delineating feasible and appropriate models of avatar use for psychotherapeutic purposes, and investigating both consumer and clinician attitudes and preferences toward the technology for this purpose, will be an important endeavor for future research.

#### AUTHOR CONTRIBUTIONS

EF conducted the literature review, and IR drafted the first version of the manuscript. NT, KW, JA, and MK contributed to and edited the final manuscript.

interviewing. In: Luxton DD, editor. *Artificial Intelligence in Behavioral and Mental Health Care*. Oxford, UK: Elsevier (2016). p. 53–79.

**Conflict of Interest Statement:** The authors declare that the manuscript was developed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Copyright © 2016 Rehm, Foenander, Wallace, Abbott, Kyrios and Thomas. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# **The Impact of a Videogame-Based Pilot Physical Activity Program in Older Adults with Schizophrenia on Subjectively and Objectively Measured Physical Activity**

*Heather Leutwyler <sup>1</sup> \*, Erin Hubbard<sup>1</sup> , Bruce Cooper <sup>2</sup> and Glenna Dowling<sup>1</sup>*

*<sup>1</sup> Physiological Nursing, University of California San Francisco, San Francisco, CA, USA, <sup>2</sup> School of Nursing, University of California San Francisco, San Francisco, CA, USA*

#### *Edited by:*

*Yasser Khazaal, Geneva University Hospitals, Switzerland*

#### *Reviewed by:*

*Jérôme Favrod, University of Applied Sciences and Arts of Western Switzerland, Switzerland Jude Uzoma Ohaeri, University of Nigeria, Nigeria Khaled M'Hiri, University Hospital of Geneva, Switzerland*

> *\*Correspondence: Heather Leutwyler<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Public Mental Health, a section of the journal Frontiers in Psychiatry*

*Received: 23 October 2015 Accepted: 07 December 2015 Published: 21 December 2015*

#### *Citation:*

*Leutwyler H, Hubbard E, Cooper B and Dowling G (2015) The Impact of a Videogame-Based Pilot Physical Activity Program in Older Adults with Schizophrenia on Subjectively and Objectively Measured Physical Activity. Front. Psychiatry 6:180. doi: 10.3389/fpsyt.2015.00180* **Objectives:** The purpose of this report is to describe the impact of a videogame-based pilot physical activity program using the *Kinect for Xbox 360* game system (Microsoft, Redmond, WA, USA) on physical activity in older adults with schizophrenia.

#### **Methods:** In this one group pre-test, post-test pilot study, 20 participants played an active videogame for 30 min, once a week for 6 weeks. Physical activity was measured by self-report with the Yale Physical Activity Survey and objectively with the Sensewear Pro armband at enrollment and at the end of the 6-week program.

**Results:** There was a significant increase in frequency of self-reported vigorous physical activity. We did not detect a statistically significant difference in objectively measured physical activity although increase in number of steps and sedentary activity were in the desired direction.

**Conclusion:** These results suggest participants' perception of physical activity intensity differs from the intensity objectively captured with a valid and reliable physical activity monitor.

**Keywords: schizophrenia, physical activity, videogame**

## **INTRODUCTION**

Older people with schizophrenia tend to spend the majority of their time in sedentary activity (1). Prolonged sedentary activity is associated with various negative health outcomes including poor physical fitness (2). The negative impact of sedentary activity is problematic for any adult, but is particularly burdensome for older adults with schizophrenia. People with schizophrenia have a higher mortality rate than the general population and sedentary behavior contributes to this mortality gap (3, 4). Even small reductions in sedentary behavior, such as short activity intervals of 10 min or less, may positively influence physical and mental health (5).

Despite the obvious need for physical activity programs to decrease sedentary time in older adults with schizophrenia, few interventions exist. Most of the physical activity research in serious mental illness has focused on younger to middle-aged adults (6). In a 2010 Cochrane review, the efficacy of three physical activity RCTs (e.g., walking, weight training) in people with severe mental illness (SMI) was evaluated (6). The authors concluded that the impacts of these programs on health

Leutwyler et al. Physical Activity

outcomes were mixed, but some studies provided evidence of improved fitness. Two physical activity RCTs for people with SMI published after the Cochrane review also produced mixed outcomes. One study provided evidence of a positive impact on weight change but did not report information about impact on physical activity (7). Another study showed a positive impact on self-reported physical activity levels (8).

Not only do we need effective physical activity programs for older adults with schizophrenia but we also need programs that will successfully engage older adults with schizophrenia (6, 9). Videogame-based exercise may be one way to promote physical activity in this vulnerable population (10, 11). Videogames with an interface that requires physical exertion to play, such as the *Kinect for Xbox 360* game system (Microsoft, Redmond, WA, USA), promote physical activity (11, 12). Participants use their body to control the game with the *Kinect's* full-body tracking sensor system that recognizes the participant's body and mirrors those movements in the game.

We designed and tested a videogame-based physical activity program designed to keep older adults with schizophrenia engaged and motivated to participate in physical activity. (10, 11) Consistent with previous findings from videogame research, (13) as our participants became more involved and successful with active videogames, they developed skills that made it easier to engage in activity (10). One of the study objectives was to examine the impact of the program on physical activity in participants' every day life. The purpose of this report is to describe the impact of a videogame-based physical activity program using the *Kinect for Xbox 360* game system (Microsoft, Redmond, WA, USA) on frequency of vigorous physical activity in older adults with schizophrenia.

#### **MATERIALS AND METHODS**

#### **Design**

A one-group pre-test, post-test design was used to examine the impact of our pilot program on physical activity. Institutional review board approval was obtained from the University's Committee on Human Research. Anonymity and confidentiality were maintained according to their guidelines.

#### **Participants and Settings**

Inclusion criteria were that participants be: (1) at least 55 years of age or older; (2) diagnosed with schizophrenia or schizoaffective disorder; and (3) competent to consent based on an evaluation of their comprehension of the consent form. A convenience sample of participants from four different facilities were recruited by facility staff and referred to the researchers. Study fliers were also posted. Patients with a history of a prior myocardial infarction, uncontrolled hypertension, history of angioplasty, history of angina, and/or use of nitroglycerin to treat angina were excluded.

#### **Procedures**

Recruitment and data collection began in May 2012 and concluded in June 2013. The principal investigator and her research staff facilitated the weekly exercise sessions. Once a week for 6 weeks, participants played an active videogame, using the *Kinect for Xbox 360* game system (Microsoft, Redmond, WA, USA), for 30-min. Although current recommendations for adults are to engage in moderate intensity physical activity 150 min each week, (14) the focus of this pilot study was to determine feasibility, acceptability, and adherence to the program. Therefore, we chose a short frequency and duration for our program to first establish participant participation in the program.

At each weekly session, participants choose from a variety of games and were encouraged to use different games each week. Offthe-shelf videogames played included: *Kinect Sports*(e.g., bowling, golf, skiing, darts), *Kinect Carnival Games*, *Kinect Dance Central 2*, *Kinect Adventures*, and *Kinect Your Shape Fitness Evolved*. Games played most often were: bowling, dance, carnival games, skiing, Tai Chi (from the Fitness game), baseball, darts, golf, river rafting, and 20,000 leaks under the sea.

Participants engaged in the program in groups of three to four at a time. The program took place at the facility the person attended: an outpatient community treatment center, a locked mental health facility, a transitional residential facility, or a skilled nursing facility.

Each participant had an appropriate amount of space in order to achieve full range of motion. Approximately 6 feet of free space between the participant and the *X-Box Kinect* sensor was needed. The games offered a variety of levels and each group started off at the beginner level. Participants were taught warning signs to be aware of while exercising (e.g., shortness of breath, dizziness), were encouraged to discontinue the game if they noticed any exercise warning signs and to notify the research staff.

#### **Measures**

A demographic questionnaire obtained information on age, gender, race, smoking status, and living situation at enrollment.

#### Physical Activity

Subjective assessment of physical activity was assessed with the Yale Physical Activity Scale (YPAS). (15) The YPAS is based on self-report and measures five activity dimensions (Vigorous activity, Leisurely walking, Moving on feet, Standing, and Sitting) that occur during a typical week over the past month. Eight summary scores are calculated that include: total time spent per week in all physical activities, total energy expenditure in kcal per week, five individual indices for the activity dimensions, and a total activity dimension index. Indices are calculated from the frequency, duration, and intensity of activities. Preliminary data supports the use of YPAS as a self-report measure of physical activity in older adults with schizophrenia (16). The YPAS was completed at enrollment into the study and upon completion of the final group at week 6.

Objective assessment of physical activity was measured with the SenseWear Pro armband™ (SWA; BodyMedia Inc., Pittsburgh, PA, USA). Participants wore the device for 7 days between week 1 and week 2 and again between week 5 and week 6 over the left triceps muscle at all times except during bathing or water activities. This device samples data from a heat-flux sensor, a galvanic-skin-response sensor, a skin-temperature sensor, a near-body-temperature sensor, and a bi-axial accelerometer. Previous research doucmented that the SWA accurately estimates energy expenditure in older adults. (17) Outcome variables measured with this instrument included daily steps taken during a week and weekly hours of physical activity categorized as sedentary [0–2.9 metabolic equivalents (METS)], moderate (3–5.9 METS), vigorous (6–8.9 METS), and very vigorous (*≥*9 METS). The data can be reduced to a single number in order to determine if activity levels improved during the course of the program. Participants were fitted with the SWA and informed about the activities the device would monitor during data collection. Participants were reminded to take the SWA off only when showering or performing other activities during which the device might get wet. Additionally, they were given an information sheet that described proper placement and contact information for study staff if they had questions at any time. The devices were returned at the next videogame session. If the participant was unable to attend, arrangements were made for a convenient time and location for retrieval.

Adherence was measured with a count of sessions attended and with total minutes attended out of the possible total minutes of attendance. Total possible minutes for the six sessions were 180. The PI or research assistant (RA) logged the participant's attendance at each session. The PI or RA monitored participants throughout the session in order to determine the number of minutes attended as participants were allowed to leave at any point during the group.

#### **Data Analysis**

Statistical analyses were performed using STATA version 13. Descriptive statistics and frequency distributions were generated for sample characteristics. Change in self-reported vigorous physical activity with the YPAS was analyzed with a non-parametric bootstrapped repeated measures *t*-test using bias-corrected and accelerated confidence intervals with 5,000 repetitions to compensate for the non-normal distribution of difference scores.

Change in objectively measured physical activity from week 1 to week 6 was evaluated with a change score coded as a dichotomy, with positive change (i.e., increase) coded 1 and negative (i.e., decrease) or no change coded as 0, subtracting the total amount of activity measured during week 1 from week 6. This approach accommodated the extreme variation in the small number of reports (e.g., SD almost seven times greater than the mean for change in sedentary hours reported) by allowing a simple binomial test for change.

#### **RESULTS**

A total of 20 participants that took part in the study completed the physical activity assessments and are included in the analyses. Sociodemographic and clinical characteristics are presented in **Table 1**. The majority of participants were male and the average age was 60 years. More than half of the patients were current or previous smokers.

The mean number of groups attended was 5.6 out of 6 total (SD = 0.8) and the mean total minutes attended were 169 out of 180 total (SD = 23.7). Seventy percent of participants (*n* = 14) had perfect attendance (i.e., attended six out of six sessions), four

#### **TABLE 1 | Clinical characteristics**.

participants attended five sessions, one participant attended four sessions, and one participant attended three sessions.

Vigorous physical activity was defined as any activity that lasted at least 10 min and caused large increases in breathing, heart rate, or leg fatigue, or caused the person to perspire. At enrollment in the study, 13 participants reported no vigorous activity, 4 participants reported vigorous activity 1–3 times a month, 1 participant reported vigorous activity 1–2 times per week, 1 participant reported vigorous activity 3–4 times per week, and 1 participant reported vigorous activity 5 or more times per week. At completion of the study, nine participants reported no vigorous activity, four participants reported vigorous activity one to three times a month, one participant reported vigorous activity one to two times per week, three participants reported vigorous activity three to four times per week, two participants reported vigorous activity five or more times per week, and one did not know. With the non-parametric bootstrapped repeated measures *t*-test using bias-corrected and accelerated confidence intervals (95% CI) and alpha equal to 0.05, we detected a significant increase in frequency of self-reported vigorous physical activity from enrollment to the end of the program for an average increase of 0.9 points (95% CI: 0.35–2.45). This difference constitutes a standardized effect of 0.46 [Cohen's *d*; (18)], which is in the "medium effect size" range.

Fifteen of the 20 participants wore the SWA. Five participants chose not to wear the SWA. As indicated in**Table 2**, 10 participants increased the number of steps taken during the period between enrollment to program completion and 5 showed no increase. Nine participants had a decrease in the amount of time spent in sedentary activity while six had no increase. Eight participants increased the amount of time spent in moderate activity, and seven showed no increase. We did not detect any vigorous or very vigorous activity. None of these differences were statistically significant in this small sample, although increase in the number of steps taken (67% increased), and the reduction in sedentary activity (61% decreased) were in the desired direction.

#### **TABLE 2 | Objective physical activity results**.

#### **DISCUSSION**

Our videogame-based physical activity program is the first in the literature to show a significant positive impact on the amount and frequency of physical activity in older adults with schizophrenia. While participants self-reported significantly more vigorous physical activity, we did not find a statistically significant difference in objectively measured physical activity. However, the majority of participants increased their number of steps and spent less time in sedentary activity at program completion. It was interesting to find that although we did not detect any vigorous or very vigorous activity with our monitors, participants self-reported an increase in vigorous activity at program completion. Further research need to be done to better understand the differences between perceived and actual levels of physical activity in this population. It is possible that when a sedentary patient begins an exercise program, the patient perceives the activity to be more vigorous than what is objectively recorded by an activity monitor. These data also suggest that our program is an ideal way to begin a physical activity program because it allows participants to begin activity in a safe and feasible manner while providing the opportunity to decrease sedentary activity and increase daily steps taken.

Interestingly, Lindamer et al. (16) also found that older patients with schizophrenia self-reported vigorous activity differed from objectively measured vigorous activity. Soundy et al. (19) conducted a systematic review to identify and synthesize the evidence about levels of physical activity in adults with serious mental illness. Not surprisingly, the authors found that patients spent more time per week in sedentary activity and less time per week in moderate and vigorous activity compared to healthy controls. Physical activity was measured in a variety of ways in these studies, including both actigraphy and self-report with the IPAQ. These authors encourage the use of both rigorous self-report questionnaires as well as accelerometers to capture the range of physical activity. Our results also highlight the importance of evaluating physical activity with both objective and subjective measures in order to capture the full spectrum of activity and inactivity.

Similar to our results, Bartels et al. (8) found in their physical activity program (In SHAPE) for adults of all ages with serious mental illness, that intervention participants self-reported twice as much moderate to vigorous activity compared to controls. The intervention group also had significantly greater total MET minutes of vigorous activity. Their measure of physical activity was self-report using the International Physical Activity Questionnaire (IPAQ). In contrast to the YPAS, the IPAQ only assesses moderate and vigorous physical activity. Other researchers have suggested that the YPAS may be more likely to capture light activity than an objective physical activity monitor (16). The intervention for the In SHAPE program consisted of 1 year of weekly sessions with a fitness trainer plus a fitness club membership. This approach may have also offered a way for participants to begin a physical activity program in an individualized way that was safe and approachable.

Recent research suggests that promoting light intensity physical activity may be a feasible approach to ameliorate the deleterious health consequences associated with sedentary behavior (20). Low levels of physical activity in combination with prolonged sitting time are associated with negative health outcomes (20, 21). Greater sedentary time has been associated with an increased risk for all-cause mortality in the general population (22). Our program may be an avenue to break up prolonged sitting time because it is a feasible gentle physical activity program to begin with that can be adapted to become more strenuous as participants become adept at both playing the games and more comfortable with engaging in physical activity.

Our study has several limitations. Since this was a pilot feasibility study, participants engaged in the program only once a week for 30 min. Perhaps with more frequent activity, the impact on objective measures would have been more pronounced. In addition, the majority of the participants were male. In order to determine if the program is helpful for both men and women, in future work we will attempt to recruit and enroll more females. The lack of a control group makes it difficult to fully understand the impact of the program on participants' physical activity levels. One of the purposes of the study was to determine which games participants preferred however this could have influenced individual participants' activity levels differently. In future work, we plan to standardize the games played during the course of the study so that participants all experience the same games for equal amounts of time. Despite the limitations, our study provides important preliminary data about the initial efficacy of a novel videogame-based physical activity program that has potential to improve physical activity and health outcomes in people with schizophrenia.

Our results indicate that participants have a positive attitude toward videogame-based physical activity. Although participants' perception was that of engaging in vigorous activity, our objective monitor did not detect vigorous activity. However, objectively measured physical activity did increase, showing a trend toward improvement. With a larger sample, more frequent exercise, and increased exercise duration, we hope to see a significant improvement in objectively measured activity. For example, with 40 participants, the medium effect size for change in sedentary time would be statistically significant with alpha = 0.05 (twosided) and power = 0.80. The results from this study represent an important "first step" toward the creation of a novel and effective physical activity program for older adults with schizophrenia that may be easily incorporated into the daily routine of mental health facilities.

#### **AUTHOR CONTRIBUTIONS**

HL, EH, BC, and GD made substantial contributions to the conception of the work, analysis and interpretation of the data for the work. HL and EH made significant contributions to the acquisition of the data. HL drafted the work. HL, EH, BC, and GD revised the work critically for important intellectual content, approved the final version, and agree to be accountable for all aspects of the work.

#### **REFERENCES**

#### **FUNDING**

This work was supported by the National Center for Research Resources (KL2R024130 to HL and UCSF-CTSI Grant Number UL1 RR024131) and the National Institute on Aging (K23AG04438). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The reviewer Jerome Favrod and handling Editor Yasser Khazaal declared a current collaboration and the handling Editor states that the process nevertheless met the standards of a fair and objective review.

*Copyright © 2015 Leutwyler, Hubbard, Cooper and Dowling. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# **Reducing delusional conviction through a cognitive-based group training game: a multicentre randomized controlled trial**

*Yasser Khazaal <sup>1</sup> \*, Anne Chatton <sup>1</sup> , Karen Dieben <sup>1</sup> , Philippe Huguelet <sup>1</sup> , Maria Boucherie <sup>1</sup> , Gregoire Monney <sup>1</sup> , Laurent Lecardeur <sup>2</sup> , Virginie Salamin <sup>3</sup> , Fethi Bretel <sup>4</sup> , Silke Azoulay <sup>5</sup> , Elodie Pesenti <sup>6</sup> , Raoul Krychowski <sup>7</sup> , Andreia Costa Prata <sup>7</sup> , Javier Bartolomei <sup>1</sup> , Perrine Brazo <sup>2</sup> , Alexei Traian <sup>8</sup> , Thomas Charpeaud <sup>9</sup> , Elodie Murys <sup>10</sup>, Florent Poupart <sup>11</sup> , Serge Rouvière <sup>12</sup>, Daniele Zullino <sup>1</sup> , Alberto Parabiaghi <sup>13</sup>, Mohamed Saoud 12,14,15 and Jérôme Favrod <sup>16</sup>*

#### *Edited by:*

*Alexandre Andrade Loch, University of São Paulo, Brazil*

#### *Reviewed by:*

*Erica Toledo Piza Peluso, Universidade Bandeirante Anhanguera, Brazil Rafael Teixeira De Sousa, National Institutes of Health, USA*

#### *\*Correspondence:*

*Yasser Khazaal, Geneva University Hospitals, Grand Pré, 70C, Geneva 1206, Switzerland<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Public Mental Health, a section of the journal Frontiers in Psychiatry*

> *Received: 23 February 2015 Accepted: 14 April 2015 Published: 28 April 2015*

#### *Citation:*

*Khazaal Y, Chatton A, Dieben K, Huguelet P, Boucherie M, Monney G, Lecardeur L, Salamin V, Bretel F, Azoulay S, Pesenti E, Krychowski R, Costa Prata A, Bartolomei J, Brazo P, Traian A, Charpeaud T, Murys E, Poupart F, Rouvière S, Zullino D, Parabiaghi A, Saoud M and Favrod J (2015) Reducing delusional conviction through a cognitive-based group training game: a multicentre randomized controlled trial. Front. Psychiatry 6:66. doi: 10.3389/fpsyt.2015.00066* *<sup>1</sup> Geneva University Hospitals, Geneva University, Geneva, Switzerland, <sup>2</sup> Service de Psychiatrie, CHU de Caen, Université de Caen Basse-Normandie, UMR6301 ISTCT, ISTS Team, Caen, France, <sup>3</sup> Fribourg Network for Mental Health, Fribourg, Switzerland, <sup>4</sup> Service de Psychiatrie Ambulatoire et de Réhabilitation du Pôle Rouen Rive Droite, Centre Hospitalier du Rouvray, Centre de Jour Saint-Gervais, Rouen, France, <sup>5</sup> Centre Psychosocial, Biel, Switzerland, <sup>6</sup> MIDI Foyer SISP EMS, Yverdon Les Bains, Switzerland, <sup>7</sup> La Borde, Foyer SISP EMS, Lausanne, Switzerland, <sup>8</sup> Centre Medico-Psychologique B, Centre Hospitalier Universitaire, Clermont-Ferrand, France, <sup>9</sup> Service de Psychiatrie, Centre Hospitalier de Vichy, Vichy, France, <sup>10</sup> Unité Mobile de Psychiatrie, Centre Hospitalier Princess Grace, Monaco, Monaco, <sup>11</sup> Léon-Jean Grégory Hospital, Thuir, France, <sup>12</sup> CRESOP, Centre Hospitalier le Vinatier, Bron, France, <sup>13</sup> Laboratory of Epidemiology and Social Psychiatry, IRCCS 'Mario Negri' Institute for Pharmacological Research, Milan, Italy, <sup>14</sup> EA 4615, Université de Lyon, Lyon, France, <sup>15</sup> Université Lyon 1, Lyon, France, <sup>16</sup> School of Nursing Sciences La Source, University of Applied Sciences and Arts of Western Switzerland, Lausanne, Switzerland*

Objective:"Michael's game" (MG) is a card game targeting the ability to generate alternative hypotheses to explain a given experience. The main objective was to evaluate the effect of MG on delusional conviction as measured by the primary study outcome: the change in scores on the conviction subscale of the Peters delusions inventory (PDI-21). Other variables of interest were the change in scores on the distress and preoccupation subscales of the PDI-21, the brief psychiatric rating scale, the Beck cognitive insight scale, and belief flexibility assessed with the Maudsley assessment of delusions schedule (MADS).

Methods: We performed a parallel, assessor-blinded, randomized controlled superiority trial comparing treatment as usual plus participation in MG with treatment as usual plus being on a waiting list (TAU) in a sample of adult outpatients with psychotic disorders and persistent positive psychotic symptoms at inclusion.

Results: The 172 participants were randomized, with 86 included in each study arm. Assessments were performed at inclusion (T1: baseline), at 3 months (T2: post-treatment), and at 6 months after the second assessment (T3: follow-up). At T2, a positive treatment effect was observed on the primary outcome, the PDI-21 conviction subscale (*p* = 0.005). At T3, a sustained effect was observed for the conviction subscale (*p* = 0.002). Further effects were also observed at T3 on the PDI-21 distress (*p* = 0.002) and preoccupation

subscales (*p* = 0.001), as well as on one of the MADS measures of belief flexibility ("anything against the belief") (*p* = 0.001).

**Conclusion:** The study demonstrated some significant beneficial effect of MG.

**Keywords: psychotic disorders, schizophrenia, cognitive therapy, game, hypothetical reasoning, randomized controlled study, psychotherapy**

#### **Introduction**

A considerable proportion of patients with psychotic disorders do not respond fully to antipsychotic agents (1). As an adjunct treatment, however, cognitive behavioral therapy (CBT) has, to some extent, a favorable effect on psychotic symptoms (2–7), awareness of illness, distress, preoccupation, conviction, and behavioral consequences of delusional beliefs (8–11). A core component of CBT is based on hypothetical reasoning, which consists of the search for alternative explanations for a given experience (12). Delusions are associated with low belief flexibility, with most patients unable to spontaneously find alternative explanations for their beliefs (13). Promoting an alternative hypothesis may reduce their degree of conviction, preoccupation, and distress associated with delusions (14, 15).

Despite an increasing need for trained professionals who are able to deliver CBT for psychotic symptoms in naturalistic settings, studies have emphasized that training opportunities are lacking and that the numbers of qualified therapists are poor (16– 18). Moreover, most studies in the field have been performed in CBT specialized settings with highly selected patients (19). A number of preliminary studies have shown, however, that new tools that integrate CBT techniques in game format (20, 21) and some forms of computer-assisted therapy (22) represent promising treatment for patients with psychotic disorders.

"Michael's game" (MG) (**Table 1**) is a hypothetical reasoning training module that promotes the dissemination of CBT (specifically, reasoning training) in natural clinical settings. It is based on CBT of psychotic symptoms (5, 23, 24), as described elsewhere (20, 21). The aim of the game is to train people to find alternative hypotheses for a given situation.

Two preliminary studies (20, 21) support the possible impact of the game on psychotic symptoms.

Those earlier studies had, however, a number of limitations such as lack of control group, lack of blind assessment, the noncontrolled character of the pharmacological treatments, as well as the lack of follow-up measures.

Furthermore, the consistency of the intervention was not controlled by audio recording of the sessions. The study at hand aimed to overcome the weakness of the previous works with more rigorous methods such as a randomized controlled design, blind assessments, sessions recording, and a follow-up assessment.

In the present randomized controlled trial, we hypothesized a more important impact of "treatment as usual + Michael's game" (MG) than of "treatment as usual + waiting list" (TAU) on a measure of psychotic symptoms related to conviction (primary outcome) and possibly on measures of distress, preoccupation, symptom intensity, belief flexibility, cognitive insight, awareness of illness, and actions on beliefs (secondary outcomes).

#### **TABLE 1 | "Michael's game."**

#### **Examples of objectives on the cards**

Describe a situation before interpretation Devise the interpretation of a situation as a hypothesis Search for different interpretations of the same situation Identify the cognitive and behavioral consequences of the different hypotheses Search for a link between the interpretation given for a situation and a personal real-life experience Put the hypotheses in hierarchical order in terms of their probability Search for arguments for or against a hypothesis Think of a way of testing a given hypothesis in reality **Examples of cards** *A non-psychotic and non-emotional situation card* Michael sets two bags of different sizes on each side of a scale The big bag has the same weight as the small bag Michael is surprised since the two bags are supposed to be filled with cotton He thinks that the small bag contains a stone

*A psychotic card*

Michael is watching his favorite show on television When the show host appears, Michael is so pleased that he bursts out laughing The show host and another participant in the show start laughing at the same time Michael tells himself: "My joy is contagious"

*The game was conceived by two of the authors, Yasser Khazaal and Jerome Favrod. It has been translated into English, French, Spanish, German, and Italian. The game includes non-psychotic, non-emotional cards (1–11); emotional, non-psychotic cards (12–32); and psychotic cards (33 to the end).*

The aim of the trial is to assess the short-term effect (postintervention) of MG in comparison to TAU on the primary outcome and on further secondary outcomes. The sustained or long-term effect of the intervention in comparison to TAU was also evaluated 6 months after the post-intervention assessment of the primary and secondary outcomes.

#### **Materials and Methods**

Participants were outpatients recruited in psychiatric rehabilitation units and outpatient clinics in Switzerland, France, Monaco, and Italy. Potential participants were identified through systematic screening of medical records. Written informed consent was obtained from all participants. Institutional review boards and the ethical committees in Switzerland, France, and Italy approved the study protocol. The protocol was also made available to all study investigators and was registered (International Standard Randomized Controlled Trial Number Register: ISRCTN37178153)<sup>1</sup> . The study was carried out from October 2008 to September 2011. The study's duration was longer than initially expected because of a delay in the recruitment process. The study had, however, slightly higher recruitment of participants than first planned (172 rather than 166) and a higher retention rate than originally expected (124

<sup>1</sup> http://www.controlled-trials.com/ISRCTN37178153/

patients assessed at the end point rather than the 94 projected). There were no other deviations from the original study protocol.

#### **Randomization**

Eligible patients were randomized to either TAU or to MG after providing informed consent. The randomization scheme was generated by using the website randomisation.com<sup>2</sup> and kept independently by a statistician. The allocation ratio used was one to one. A permuted-block randomization procedure was used with fixed block sizes of four patients, ensuring that the number of subjects in the different groups closely balanced at all times. The study investigators, who were in charge of enrollment, were blinded to the randomization sequence in order to prevent them from predicting patient allocation, thus reducing selection bias. There was no randomization by center.

#### **Assessment Procedures**

Patients were assessed at baseline (T1); at 3 months, after the end of the MG sessions (T2); and 6 months after the second assessment (T3). Psychologists or psychiatrists made the assessments independently from the therapists, and the game leaders and were not informed of the treatment received by the participants (blind evaluation). The patients were given 40 Swiss francs (approximately 35 Euros or 40 US Dollars) as compensation after each evaluation.

#### **Measures**

phenomena related to the principal abnormal belief of a patient. In practice, the MADS improves the assessment of the possible impact of the game on specific and individualized aspects of the main delusional idea of each included patient and on measures of belief flexibility specifically linked with the main delusional belief. The following MADS assessments were included in the study:

#### **Primary Outcome**

The primary outcome was the change after treatment in the conviction score of the PDI-21.

#### **Secondary Outcomes**

The 16 secondary outcomes included the change in scores on the other two subscales of the PDI-21 (distress and preoccupation), the five subscales of the BPRS, the two subscales of the BCIS, the GAF, the SOFAS, and the five items of the MADS.

#### **Sample Size and Power**

An *a priori*sample size was estimated from a pilot study (21), using the conviction subscale of the PDI-21 in the calculation. By using the Diggle formula for the sample size calculation in longitudinal data, we found that a sample size of at least 47 persons per group was needed at each study evaluation (error rate of 0.05; statistical power of 0.8).

#### **Inclusion Criteria**

#### **Exclusion Criteria**

#### **Interventions**

#### Michael's Game

Michael's game is a collaborative group game consisting of 80 cards (**Table 1**). Each card corresponds to a situation and to objectives

<sup>2</sup> http://www.randomization.com

that target the ability to reason with hypotheses (see **Table 1** for an example of a card). Training group leaders (two per session) direct the game during weekly sessions lasting for about 1 h. Because MG is an 80-card game, the mean number of sessions needed to end the game is not *a priori* fixed. The mean number of sessions needed to end the game was 12.1 (SD = 3.41). The mean participation rate of the participants (number of sessions completed by a participant *×* 100/total number of sessions needed to complete the program in the same group) was 91.2% (SD = 14.1). These figures are similar to those described in the preliminary reports related to the game (20). Failure to attend more than three sessions was considered to be MG treatment discontinuation. Participants (in groups of four to eight patients) are led through specific questions to find multiple answers (hypotheses) to the questions and conclusions that Michael draws from the situations that he is confronted with. In other words, participants have to help Michael to find alternatives to the conclusions that he draws from situations described on each card. MG was conceived as a collaborative group card game in order to allow patients to become partners of a fictive character (Michael) and together to interact with cards containing impersonal information that may reflect their own concerns. Participants play together on objectives such as the following: describe the situation reported on a given card,

identify Michael's hypothesis, search for different hypotheses that may explain the same situation, report the possible cognitive and behavioral consequences of the different hypotheses, give arguments for or against a given hypothesis, and imagine how to test a given hypothesis in reality. Game directors were psychiatric care workers (nurses: 14, psychologists: 12, psychiatrists: 6) who were specifically trained to deliver MG according to the training model described below.

#### Treatment as Usual Plus Waiting List (TAU; Control Condition)

Treatment as usual comprises case management, psychosocial interventions, antipsychotic medication, and outpatient and community follow-up. The patients in the TAU condition had to wait until the end of follow-up before participating in a MG.

The collaborative centers had access to similar pharmacological treatment, psychosocial structures, and level of medical training. Medication was monitored during the study. Chlorpromazine equivalences were calculated for antipsychotic medications according to Woods (34). Participants from both groups received treatment as usual throughout the entire study period.

**TABLE 2 | Baseline sociodemographic and clinical characteristics of the participants in the Michael's game (MG) and the treatment as usual (TAU) groups**.

Khazaal et al. A game for hypothetical reasoning

*Summary statistics report means and SDs or percentages.*

*TAU, treatment as usual plus waiting list; MG, treatment as usual plus Michael's game; PDI, Peters delusions inventory; BCIS, Beck cognitive insight scale; MADS, Maudsley assessment of delusions schedule; BPRS, brief psychiatry rating scale; GAF, global assessment of functioning; SOFAS, social and occupational functioning assessment scale.*

#### **Quality Assurance**

Group directors at each of the 16 collaborative centers (nurses, psychologists, psychiatrists) were trained by the same method: a standardized 1 h presentation and a 1 h training session for the game. Training was directed by one of the game's authors or by one person authorized by the authors for his or her educational qualities and experience in directing the game. Supervision was also offered to game directors by the first author upon request. Sessions were audiotaped (not available for all centers) to check their fidelity to the intervention and were assessed with expected therapist strategies extracted from the collaboration, interpersonal effectiveness, understanding, and guided discovery items of the Haddock scale (35). Twenty-five randomly selected sessions were assessed. The percentage of items rated as being compliant with the desirable strategies ranged from 72 to 100%.

#### **Statistical Analyses**

At the patient level, baseline differences were checked between the two study groups, as well as differences between completers and non-completers using *t*-tests, chi-square tests, or Fisher's exact tests where applicable.

The direct effect, or the short-term effect, of treatment on the primary and on the secondary continuous outcomes was evaluated through analyses of covariance (ANCOVAs) by considering outcome values after the intervention at T2 and adjusting for the respective baseline outcomes. The treatment group served as the between-subject factor. These analyses were also controlled for center to correct for a possible cluster effect and for medication. Similarly, the long-term effect at T3 of the intervention was measured by ANCOVAS, using outcome values at T3 and adjusting for the respective baseline outcomes. Finally, categorical MADS variables were analyzed at T2 (short-term effect) and T3 (longterm effect) through logistic regression analyses, with treatment group as the between-subject factor, and were also adjusted for baseline outcomes and controlled for center and medication. The necessary application conditions of all these models were checked and met.

#### **TABLE 3 | Evolution of primary and secondary outcome variables by treatment group**.

*<sup>a</sup>p-value resulting from analysis of short-term treatment effect.*

*<sup>b</sup>Only significant results after Bonferroni's correction are reported.*

*<sup>c</sup>p-value resulting from analysis of long-term treatment effect.*

*<sup>d</sup>n.s., not significant.*

*Interval variables are reported by their mean and SD [M (SD)] and categorical variables by their percentage (%).*

*TAU, treatment as usual plus waiting list; MG, treatment as usual plus Michael's game; T1, baseline; T2, at 3 months post-treatment; T3, at 6 months follow-up; PDI, Peters delusions inventory; BCIS, Beck cognitive insight scale; BPRS, brief psychiatry rating scale; GAF, global assessment of functioning; SOFAS, social and occupational functioning assessment scale.*

*Bold font indicates significant p-value.*

#### Adjusting for Multiple Testing

#### Treatment of Missing Data

The trial was *a priori* powered for multiple time points at a predefined 0.05 significance level, using PDI-21 conviction as the primary outcome. Therefore, this level of significance was kept when the primary outcome results were interpreted. However, to minimize the chance of spurious results pertaining to the secondary outcomes, we adjusted them for multiple testing by Bonferroni's correction (α *≤* 0.05/16 = 0.0031). All the statistical analyses were performed with the Statistical Package for the Social Sciences (SPSS version 18.0, IBM, Chicago, IL, USA).

Analyses were done on an intention-to-treat basis, whereby all randomized subjects were included. Categorical missing data were imputed using logistic regressions. Quantitative missing data were imputed by the expectation–maximization algorithm, a statistical simulation technique that estimates the averages, the matrix of variance and covariance, and the matrix of correlations. After convergence, missing data are replaced by the estimation obtained and the completed data are then analyzed by the usual methods.

#### **Results**

After screening and informed consent, 172 patients were included and randomized for study participation (**Figure 1**).

#### **Baseline Characteristics of Subjects**

The mean age of the sample was 37.1 years (SD = 10.4). A high school diploma or a university degree had been attained by 27.1% of participants. Most participants had a diagnosis of schizophrenia (81.4%), were single (78.5%), lived in a private residence (59.3%), and had a disability pension (73.1%). Concurrent psychiatric disorders at inclusion were common [i.e., substance use (15.6%); anxiety disorders (27.2%)].

At baseline, the PDI-21 distress score was higher for the MG group than for the TAU group at a trend level (*p* = 0.05). There were no differences in the other main clinical measures (**Table 2**).

#### **Dropouts**

At T2, dropout was associated with treatment allocation (*p* = 0.01). Twenty-three of the TAU group patients and 10 of the MG group patients discontinued the study. At T2, dropout was also associated with younger age (*p* = 0.02). Furthermore, dropouts were more common among patients who dismiss the belief in response to hypothetical contradiction (*p* = 0.04) and those more able to plan a behavioral experiment (*p* = 0.04). There was no other statistically significant difference on the other sociodemographic and clinical characteristics. Dropout at T3 was associated with a younger age (*p* = 0.05) and recruiting centers, where Switzerland had a statistically significant high rate of dropouts during this period compared with the other centers (*p* = 0.01). No other statistically significant difference was observed.

#### **Outcomes**

**Table 3** presents patient outcomes at baseline, 3 months, and 9 months for the MG and TAU groups. **Figure 2** depicts the evolution of the PDI conviction raw scores.

#### Short-Term Treatment Effect (at T2) on the Primary Outcome

After baseline values, medication, and the cluster effect of center were controlled for, the results of the ANCOVAS showed a short-term treatment effect for conviction (*p* = 0.005). After the intervention, the estimated mean conviction was 29.0 for the TAU group, whereas it was 24.3 for the MG group, which means a short-term treatment effect of *−*4.7 points (95% CI [*−*7.9 to *−*1.4]).

#### Short-Term Treatment Effect (at T2) on the Secondary Outcomes

No short-term effect was observed for the PDI-21 distress subscale (*p* = 0.1), but an effect was observed for preoccupation (*p* = 0.025), with an estimated mean of 22.3 for the TAU group and 19.0 for the MG group, a treatment effect of *−*3.3 points (95% CI [*−*6.2 to *−*0.4]). However, after Bonferroni's correction, this effect was no longer significant.

No short-term treatment effect was observed for either Beck self-reflectiveness (*p* = 0.08) or Beck self-certainty (*p* = 0.4). For BPRS subscores (activation, affect, positive symptoms, and resistance), no treatment effect was found (*p* = 0.6, *p* = 0.3, *p* = 0.4, and *p* = 0.4, respectively). For BPRS negative symptoms, a treatment effect was observed (*p* = 0.019) that was not sustained after Bonferroni's correction. GAF and SOFAS did not exhibit a treatment effect (*p* = 0.1 and *p* = 0.9, respectively). With regard to the MADS items, there was an effect for "anything against the belief " in which the MG group was more likely to answer "yes" than the TAU group (OR = 3.16, 95% CI [1.30–7.70], *p* = 0.01). This effect, however, was no longer significant after Bonferroni's correction.

#### Long-Term Treatment Effect (at T3) on the Primary Outcome

A sustained effect of the intervention was observed for conviction (*p* = 0.002). At T3, the estimated mean conviction was 24.6 for the TAU group, whereas it was 18.8 for the MG group, a long-term treatment effect of *−*5.7 points (95% CI [*−*9.3 to *−*2.2]).

#### Long-Term Treatment Effect (at T3) on Secondary Outcomes

A treatment effect was observed for distress, preoccupation, GAF, and SOFAS (*p* = 0.002, *p* = 0.001, *p* = 0.03, and *p* = 0.02, respectively). The mean scores for distress and preoccupation were higher in the TAU group, whereas the mean scores for GAF and SOFAS were higher in the MG group than in the TAU group. However, after Bonferroni's correction, the significance remained only for distress and preoccupation, for which treatment effects were estimated at *−*5.5 points (95% CI [*−*9.0 to *−*2.0]) and *−*5.5 points (95% CI [*−*8.6 to *−*2.2]), respectively.

Regarding MADS variables, a sustained treatment effect was observed only for "anything against the belief ": the MG group was more likely to answer "yes" than the TAU group (OR = 4.95, 95% CI [1.85–13.27], *p* = 0.001). This effect remained significant after Bonferroni's correction.

#### **Discussion**

This study investigated the effects of a hypothetical reasoning training module of short duration, called MG, in a sample of 172 outpatients with psychotic symptoms in 16 centers in France, Italy, Monaco, and Switzerland. In accord with the main hypothesis, the conviction score measured with the PDI-21 was improved in the MG condition compared with the TAU condition at T2, the post-intervention assessment. After Bonferroni's correction, no other effects on the secondary outcomes were observed at post-intervention.

Six months later, the effect observed on the conviction score of the PDI-21 was sustained. Furthermore, other effects were observed, after Bonferroni's correction, on the distress and preoccupation subscales of the PDI-21. In addition, these results in the MG group were supplemented with an improvement in belief flexibility, as measured with the MADS item "anything against the belief."

The results do not show specific effects on the BPRS scale. The observed effects occurred on more detailed measures such as the conviction subscale of the PDI-21 (the main outcome), the distress and preoccupation subscales of the PDI-21, and one of the MADS items. This pattern possibly indicates that MG increases belief flexibility and changes the relation of the participants to their symptoms to some extent. As suggested elsewhere (19), the effect of CBT on psychotic disorders is probably of more interest for outcomes such as distress, preoccupation, and conviction related to beliefs than it is for psychotic symptoms as measured by the BPRS. Indeed, through specific training on hypothetical reasoning, MG seems to promote other viewpoints about what happens (as suggested by the observed changes on the PDI-21 and on the MADS), which is considered particularly helpful to patients dealing with stressful positive symptoms (9).

In the present study, as reported in a number of other studies on psychotherapy (36–43), post-intervention effects were sustained at follow-up on the primary outcome. The further improvements observed at follow-up on some outcomes possibly suggests that the effect of the intervention fosters additional changes. One may hypothesize that the first improvements on conviction and the patient's possible appropriation of the model of reasoning with hypotheses may allow additional experiences in daily life, and then improvements for at least some patients, as suggested by a previous case report (44). Future studies are needed, however, in order to assess the process that may be involved in such supposed effects.

One can also hypothesize that the game could be used as a warm-up program before applying it to an individualized CBT intervention for psychosis. The fidelity checks indicate good fidelity to the intervention in the assessed centers. These results show that an easy-to-use program such as MG may facilitate the dissemination of CBT (specifically hypothetical reasoning training) for psychosis in natural settings. The game may also familiarize health care professionals with the use of CBT techniques for psychosis. This of particularly high interest in consideration of the scarcity of psychotherapeutic treatments offered in clinical settings for people with psychotic disorders (16, 17, 45).

Dropout was relatively low. The game format may increase therapeutic alliance, a possible mediating factor of treatment outcomes in patients with psychosis (46). This aspect was not studied in the present paper, however, and may merit further studies. Dropout at T2 was associated with variables such as a younger age and a higher percentage of participants who dismissed the belief in response to a hypothetical contradiction. These patients possibly perceived less utility in the game than other patients did. The dropout rate associated with younger participants is in accordance with other observations (47) and suggests that the module could be improved to better engage them in the intervention or could be completed with other recovery-oriented interventions and psycho-education (20, 48).

In the absence of an active control group in our study, we cannot exclude the possibility that the observed effects were due to non-specific psychotherapeutic effects such as non-specific attention and interactions with the game leaders and other patients (45, 49). In addition, the absence of audiotaped sessions in some centers to control for fidelity to the intervention by group leaders may have missed poor fidelity in some centers. The lack of precise comparison of the TAU components in the 16 centers may have influenced the results. However, the analyses were controlled for center to correct for a possible cluster effect.

The multicentre design of the study may increase the possible generalization of the results. Furthermore, as reported in other studies (50), the limited number of exclusion criteria could contribute to the external validity of the study. We cannot fully rule out the influence of factors such as comorbid disorders (i.e., substance use disorders) or variations in cognitive deficits on the treatment outcomes.

## **Conclusion**

The results of this study indicate that the use of MG, a hypothetical reasoning training module, may improve belief flexibility and selfassessment of delusion in patients with psychotic disorders in comparison with not using it. MG appears to be a short and easyto-use intervention to disseminate CBT for psychosis in routine clinical settings. Further studies with active control group are still needed to improve the understanding of the possible effect of the game.

#### **Acknowledgments**

We thank the participants and the game leaders, as well as Joanne Corpataux, Milena Kriz, Dr. Giacomini, Claude Hayoz (Fondation HorizonSud), Dr. Georges Klein, Phillippe Laffond, Prof. Eric Bonvin, Prof. Sonia Dollfus, Prof. Thierry D'Amato, Prof. Jean-Michel Llorca, Dr. George Berthon, Dr. Céline Plassereaud, Dr. Véronique Roure, Natacha Boureykoff, Marie-Josée Durak, Dr. Maria Teresa Caldera, Dr. Roberta Bossoletti, and Dario Caffaro. *Funding*: Swiss National Science Foundation Grant 32003B-121038.

## **References**

**Conflict of Interest Statement:** Yasser Khazaal and Jerôme Favrod are the authors of the game. The other co-authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Copyright © 2015 Khazaal, Chatton, Dieben, Huguelet, Boucherie, Monney, Lecardeur, Salamin, Bretel, Azoulay, Pesenti, Krychowski, Costa Prata, Bartolomei, Brazo, Traian, Charpeaud, Murys, Poupart, Rouvière, Zullino, Parabiaghi, Saoud and Favrod. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# Development of the Positive Emotions Program for Schizophrenia: An Intervention to Improve Pleasure and Motivation in Schizophrenia

*Alexandra Nguyen1 , Laurent Frobert1 , Iannis McCluskey1,2 , Philippe Golay2 , Charles Bonsack2 and Jérôme Favrod1,2\**

*1School of Nursing Science La Source, University of Applied Sciences and Arts of Western Switzerland, Lausanne, Switzerland, 2Social Psychiatry Section, Community Psychiatry Service, Department of Psychiatry, University Hospital Center, Lausanne, Switzerland*

*Edited by: Shervin Assari, University of Michigan, USA*

#### *Reviewed by:*

*Masoumeh Dejman, Johns Hopkins School of Public Heath, USA; University of Social Welfare and Rehabilitation Sciences, Iran Ehsan Moazen Zadeh, Tehran Psychiatric Institute, Iran*

> *\*Correspondence: Jérôme Favrod<EMAIL_ADDRESS>
#### *Specialty section:*

*This article was submitted to Public Mental Health, a section of the journal Frontiers in Psychiatry*

*Received: 24 November 2015 Accepted: 25 January 2016 Published: 17 February 2016*

#### *Citation:*

*Nguyen A, Frobert L, McCluskey I, Golay P, Bonsack C and Favrod J (2016) Development of the Positive Emotions Program for Schizophrenia: An Intervention to Improve Pleasure and Motivation in Schizophrenia. Front. Psychiatry 7:13. doi: 10.3389/fpsyt.2016.00013*

Objectives: The efficacy of drug-based treatments and psychological interventions on the primary negative symptoms of schizophrenia remains limited. Recent literature has distinguished negative symptoms associated with a diminished capacity to experience, from those associated with a limited capacity for expression. The positive emotions program for schizophrenia (PEPS) is a new method that specifically aims to reduce the syndrome of a diminished capacity to experience.

Methods: The intervention's vital ingredients were identified through a literature review of emotion in schizophrenia and positive psychology. The program has been beta-tested on various groups of health-care professionals.

Results: A detailed description of the final version of PEPS is presented here. The French version of the program is freely downloadable.

Conclusion: PEPS is a specific, short, easy to use, group-based intervention to improve pleasure, and motivation in schizophrenia. It was built considering a recovery-oriented approach to schizophrenia.

Keywords: schizophrenia, anhedonia, apathy, pleasure, motivation, psychosocial interventions

#### INTRODUCTION

Negative symptoms have long been recognized as a central feature of the phenomenology of schizophrenia, dating back to early descriptions by Kraepelin and Bleuler (1). They negatively affect patients' longitudinal social, occupational, and functional outcomes, as well their longterm recovery (2–5). Whereas positive symptoms (hallucinations, delusions) reflect an excess or distortion of normal functions, and negative symptoms (blunted affect, alogia, apathy–avolition, anhedonia, inattentiveness) represent the absence or reduction of normal emotions and behaviors. Negative symptoms are classified as primary or secondary. Primary negative symptoms comprise the core features intrinsic to schizophrenia itself. Secondary negative symptoms are transient;

they are attributable and temporally related to the effects of such factors as unrelieved positive symptoms, depression, the adverse effects of antipsychotic drugs (akinesia), or the social isolation imposed by the stigma of schizophrenia. Primary and secondary negative symptoms may be similar in clinical expression, despite their contrasting etiologies (6). Often, secondary negative symptoms diminish with the resolution of their causative factors.

#### Limitations of Current Techniques

The efficacy of drug-based treatments and psychological interventions on primary negative symptoms remains limited, however (7–9). Fusar-Poli et al. (9), in their meta-analysis of 6,503 patients in the treatment arm and 5,815 patients in the placebo arm, showed that most treatments reduced negative symptoms at follow-up relative to placebo: second-generation antipsychotics, antidepressants, combinations of pharmacological agents, glutamatergic medications, and psychological interventions. However, none of the treatments used reached the threshold for clinically significant improvement as measured by clinicians using the Clinical Global Impression Severity Scale. The mean percentage change in treatment groups was 16.1%, whereas the control group changed by an average 7.9%. Improvements by treatment group, compared with the control group, varied between 4.8% for first-generation antipsychotics and 12.7% for psychological treatments. There is a clear clinical need for developing treatments for negative symptoms. The lack of clinically meaningful efficacy of drug or psychological treatments is in line with clinicians' practical experiences (7, 9). The existing psychological treatments have limitations (10). Family interventions to reduce negative symptoms appear promising when combined with other interventions. However, patients who have family members willing to be involved in treatment may merely represent a subgroup of people with schizophrenia. Furthermore, families who are more willing to participate in psychosocial interventions may provide patient's with greater support anyway and thus may not represent the broader population. Psychosocial interventions, such as cognitive behavior therapy (CBT), social skills training (SST), mindfulness-based intervention (MBI), family therapy (FT), or cognitive remediation (CR), combined with SST require highly trained therapists. The vast majority of studies were not specifically designed to target negative symptoms, and most assessed negative symptoms overall, without looking for the specific effects of the intervention. Several interventions were provided over long durations, requiring a great investment in time by the patients. For example, combining CR with SST may be useful for reducing negative symptoms, particularly social withdrawal, affective flattening, and motor retardation (11, 12), or a global score of negative symptoms (13). These interventions required 32–100 h of training. One 3-year study (14) indicated that improvements in negative symptoms did not occur until the second and third years of therapy. However, a second study (15, 16) indicated improvements in negative symptoms at 12 and 24 months. These comprehensive packages are promising but involve relatively long interventions and call for a broad range of therapeutic techniques. Except SST, very few interventions are provided as group therapy. Group interventions are particularly important since they are more commonly used in community psychiatry settings, where most patients receive treatment services.

#### Experimental Objectives

Recent literature has distinguished the negative symptoms associated with a diminished capacity to experience (apathy, anhedonia) from those who were associated with a limited capacity for expression (emotional blunting, alogia) (17–20). The apathy–anhedonia syndrome tends to be associated with a poorer prognosis than the symptoms related to diminished expression, suggesting that it is the more severe facet of the psychopathology (19). This syndrome is also related to the duration of the untreated psychosis, family history of schizophrenia, and the patient's employment status during first-episode schizophrenia (21). The distinction between diminished experience and limited expression syndromes allows more specific approaches to these problems.