A case report describes the first application of VR for a Vietnam veteran suffering from PTSD [67]. As a result of VR treatment, he significantly improved on all PTSD measures and those gains remained stable at six months follow-up. A following open clinical trial demonstrated the effectiveness of VR in ten male Vietnam veterans diagnosed with PTSD [68]. They underwent eight to 16 sessions of VR exposure in two virtual environments: a virtual helicopter flying over Vietnam, and a clearing surrounded by jungle. Participants showed significant PTSD symptom reductions on the Clinician Administered PTSD Scale (CAPS) at six months follow-up, declaring symptom reductions ranging from 15 to 67% in an interview. Self-reported intrusion symptoms as measured by the Impact of Event Scale were significantly lower at three months follow-up in comparison to baseline, but not at six months follow-up. Another open trial of VR in the treatment of *N*= 21 Vietnam veterans was conducted by Ready and collaborators [69], simulating virtual environments in response to participants' memories. Participants showed significant symptom reductions at three and sixmonths follow-up, even though two participants experienced an increase in symptoms during VR exposure. A RCT using a small sample size was presented by the same research group [70]. Eleven Vietnam veterans were assigned to either ten sessions of VR exposure or presentcentered therapy, utilizing a problem-solving approach. Results indicated no significant differences between treatment groups at posttreatment and six months follow-up.

Furthermore, several studies examined the use of a virtual environment to treat veterans returning from "Operation Iraqi Freedom" who suffered from PTSD. The "Virtual Iraq/ Afghanistan" environment was adapted from the Microsoft® X-box game "Full Spectrum Warrior". Scenarios include a Middle Eastern city and a Humvee driving down a desert highway. Auditory, visual, olfactory and vibrotactile stimulation such as gunfire, weather conditions, the smell of burnt rubber and the sensation of a moving car can be adjusted. Some examples of Virtual Iraq/Afghanistan are shown in Figure 3.

Several case reports were conducted [e.g. 71, 72]. The first clinical trial assessing the effectiveness of exposure using "Virtual Iraq" indicated clinically and statistically significant symptom reduction in *N*= 20 participants [73]. In addition, McLay and collaborators [74] presented a RCT comparing the efficacy of VR exposure therapy and usual CBT in a sample of *N*= 19 Iraq veterans diagnosed with PTSD. Within the VR condition, seven out of ten participants improved at least 30% on the CAPS, while only one out of nine within the CBT condition showed similar improvement. The effectiveness of "Virtual Iraq" was also supported by Reger et al. [75] in 24 Iraq and Afghanistan veterans. Moreover, a pilot study focusing on the combination of VR exposure and cognitive enhancing medication has shown promising results [76].

Virtual Realities in the Treatment of Mental Disorders: A Review of the Current State of Research 51

However, even though treatment of persons suffering PTSD is crucial, study designs using VR seem questionable with regard to ethical concerns. Exposing war veterans or victims of terror attacks to simulated war scenarios is contra-indicated according to current research on trauma therapy. Certain phases of traumatherapy such as stabilization and development of a therapeutic relationship have to precede the processing of the traumatic experience [86]. In the studies presented here, none of these phases were considered so that VR exposure bore the risk of retraumatization. Besides, if the virtual setting does not in detail project the traumatic event, renewed traumatisation is risked. To date, long-term effects of exposing persons with PTSD to virtual environments are mostly unknown, because efficacy studies rarely collect follow-up data. Therefore, even though the use of VR technology seems feasible in the treatment of PTSD, ethical concerns and aspects with regard to therapy

**Figure 3.** Virtual Iraq/ Afghanistan scenarios. Courtesy of Virtually Better Inc. and University of

Virtual environments have also been applied in the assessment, treatment and research of other mental disorders such as eating disorders, sexual dysfunctions, schizophrenia, attention deficit disorder, and addictions. In the following, a cursory overview of VR

The first use of VR in treating *eating disorders* was accomplished by an Italian research group [87]. VR programs focused on the improvement of body image, body satisfaction and physical acceptance in obese patients and reduction of perfectionisms, body dissatisfaction

indication always need to be considered.

Southern California, Institute for Creative Technologies.

treatment approaches in those clinical pictures will be provided.

*3.4.7. Other applications*

Another VR environment was created to treat Portuguese survivors of the 1961-1974 wars in Africa. Subsequently to a case study [77], Gamito and colleagues [78] examined the effectiveness of a VR war environment to imaginal exposure and a waiting list condition. Participants in the VR condition showed significant reduction of depressive and anxiety symptoms.

An increased incidence of PTSD was also detected among the survivors of the attacks of September 11, 2001. Consequently, Difede and Hoffman developed a virtual environment simulating jets crashing into the World Trade Center, people jumping to their deaths from the buildings, and towers collapsing. A study revealed that participants in a VR condition (*n*= 9) showed significantly greater improvement on CAPS scores than the waitlist control group (*n*= 8) [79]. Findings were replicated in a following study [80].

In a further study, a VR surrounding was developed in order to treat victims of a terrorist bus bombing in Israel. The potential effectiveness of "BusWorld" was demonstrated in a study examining 30 asymptomatic participants, who showed significantly higher mean subjective units of discomfort scores (SUDS) with increasingly distressful scenarios. Treatment of a 29-year-old victim of a bus bombing using VR resulted in significant reduction of PTSD symptoms as measured by the CAPS [81].

Another field of application in the treatment of PTSD by the means of VR exposure is made up by motor vehicle accident survivors. Saraiva et al. [82] presented a case study describing positive outcomes of VR exposure of a 42-year-old female in the aftermath of a serious vehicle accident. Findings were confirmed by Beck et al. [83], who demonstrated significant reductions of re-experiencing, avoidance, and emotional numbing in six persons reporting subsyndromal PTSD after completing ten sessions of VR treatment.

A new approach of treating PTSD was introduced by Fidopiastis et al. [84]: As aforementioned, AR, referred to as Mixed Realities (MR) by the authors, are supposed to blend virtual content into the real world, which means that computer-generated objects can be superimposed on the real-world environment. In a pilot study, first promising effects of MR in the assessment of PTSD by capturing the patient's interaction with the simulated environment were demonstrated. Riva et al. [85] further advanced the approach of MR by presenting the paradigm of Interreality, which is supposed to bridge the virtual and real world by using activity sensors, personal digital assistants or mobile phones.

However, even though treatment of persons suffering PTSD is crucial, study designs using VR seem questionable with regard to ethical concerns. Exposing war veterans or victims of terror attacks to simulated war scenarios is contra-indicated according to current research on trauma therapy. Certain phases of traumatherapy such as stabilization and development of a therapeutic relationship have to precede the processing of the traumatic experience [86]. In the studies presented here, none of these phases were considered so that VR exposure bore the risk of retraumatization. Besides, if the virtual setting does not in detail project the traumatic event, renewed traumatisation is risked. To date, long-term effects of exposing persons with PTSD to virtual environments are mostly unknown, because efficacy studies rarely collect follow-up data. Therefore, even though the use of VR technology seems feasible in the treatment of PTSD, ethical concerns and aspects with regard to therapy indication always need to be considered.

**Figure 3.** Virtual Iraq/ Afghanistan scenarios. Courtesy of Virtually Better Inc. and University of Southern California, Institute for Creative Technologies.

#### *3.4.7. Other applications*

50 Virtual Reality in Psychological, Medical and Pedagogical Applications

promising results [76].

symptoms.

Several case reports were conducted [e.g. 71, 72]. The first clinical trial assessing the effectiveness of exposure using "Virtual Iraq" indicated clinically and statistically significant symptom reduction in *N*= 20 participants [73]. In addition, McLay and collaborators [74] presented a RCT comparing the efficacy of VR exposure therapy and usual CBT in a sample of *N*= 19 Iraq veterans diagnosed with PTSD. Within the VR condition, seven out of ten participants improved at least 30% on the CAPS, while only one out of nine within the CBT condition showed similar improvement. The effectiveness of "Virtual Iraq" was also supported by Reger et al. [75] in 24 Iraq and Afghanistan veterans. Moreover, a pilot study focusing on the combination of VR exposure and cognitive enhancing medication has shown

Another VR environment was created to treat Portuguese survivors of the 1961-1974 wars in Africa. Subsequently to a case study [77], Gamito and colleagues [78] examined the effectiveness of a VR war environment to imaginal exposure and a waiting list condition. Participants in the VR condition showed significant reduction of depressive and anxiety

An increased incidence of PTSD was also detected among the survivors of the attacks of September 11, 2001. Consequently, Difede and Hoffman developed a virtual environment simulating jets crashing into the World Trade Center, people jumping to their deaths from the buildings, and towers collapsing. A study revealed that participants in a VR condition (*n*= 9) showed significantly greater improvement on CAPS scores than the waitlist control

In a further study, a VR surrounding was developed in order to treat victims of a terrorist bus bombing in Israel. The potential effectiveness of "BusWorld" was demonstrated in a study examining 30 asymptomatic participants, who showed significantly higher mean subjective units of discomfort scores (SUDS) with increasingly distressful scenarios. Treatment of a 29-year-old victim of a bus bombing using VR resulted in significant

Another field of application in the treatment of PTSD by the means of VR exposure is made up by motor vehicle accident survivors. Saraiva et al. [82] presented a case study describing positive outcomes of VR exposure of a 42-year-old female in the aftermath of a serious vehicle accident. Findings were confirmed by Beck et al. [83], who demonstrated significant reductions of re-experiencing, avoidance, and emotional numbing in six persons reporting

A new approach of treating PTSD was introduced by Fidopiastis et al. [84]: As aforementioned, AR, referred to as Mixed Realities (MR) by the authors, are supposed to blend virtual content into the real world, which means that computer-generated objects can be superimposed on the real-world environment. In a pilot study, first promising effects of MR in the assessment of PTSD by capturing the patient's interaction with the simulated environment were demonstrated. Riva et al. [85] further advanced the approach of MR by presenting the paradigm of Interreality, which is supposed to bridge the virtual and real

group (*n*= 8) [79]. Findings were replicated in a following study [80].

reduction of PTSD symptoms as measured by the CAPS [81].

subsyndromal PTSD after completing ten sessions of VR treatment.

world by using activity sensors, personal digital assistants or mobile phones.

Virtual environments have also been applied in the assessment, treatment and research of other mental disorders such as eating disorders, sexual dysfunctions, schizophrenia, attention deficit disorder, and addictions. In the following, a cursory overview of VR treatment approaches in those clinical pictures will be provided.

The first use of VR in treating *eating disorders* was accomplished by an Italian research group [87]. VR programs focused on the improvement of body image, body satisfaction and physical acceptance in obese patients and reduction of perfectionisms, body dissatisfaction

and negative attitudes towards the body in anorectic patients. A few controlled studies demonstrated the effectiveness of VR in the treatment of eating disorders [88-90].

Virtual Realities in the Treatment of Mental Disorders: A Review of the Current State of Research 53

**Results**

VR

months

months

equally effective

Aviophobia 30 RCT 1 VR treatment and relaxation training were

Aviophobia 45 RCT 1 VR treatment in combination with CBT was

Aviophobia 30 RCT 1 Presence of a therapist did not influence

Aviophobia 49 RCT 8 VR and in vivo exposure were equally

Aviophobia 75 RCT 8 VR and in vivo exposure were equally

Aviophobia 30 RCT 8 VR exposure in combination with

Aviophobia 60 RCT 6 max. VR exposure, computer-aided exposure with

exposure alone

Acrophobia 33 RCT 3 VR and in vivo exposure were equally

Aviophobia 45 RCT 5 VR treatment was superior to attention

3 VR and in vivo exposure were equally

2 Exposure in vivo did not lead to any

effective, despite shorter treatment times of

significant improvements after VR exposure

effective; results stable after 6 months

equally effective; results stable after 6

placebo group on self-report measures, but not avoidance test; results not stable after 6

effective in comparison to a waitlist control group; results stable after 6 and 12 months

effective in comparison to a waitlist control group; results stable after 6 to 12 months

a therapist's assistance, and self-administered computer-assisted exposure were equally effective; results stable after 12 months

biofeedback was more effective than VR

5 Modified 3D computer games were effective in the treatment of arachnophobia

> 83% of the VR exposure group showed clinically significant improvement, in

comparison to 0% of the waitlist control group

effectiveness of VR treatment

and superior to bibliotherapy

more effective than CBT alone

effectiveness of VR treatment

**Study Clinical**

*Fear of heights*  **Coelho et al. (2008)**

**Emmelkamp et al. (2001)**

**Emmelkamp et al. (2002)**

*Fear of flying*

**Malty et al. (2002)**

**(2001)**

**(2003)**

**(2006)**

**(2000)**

**(2006)**

**Mühlberger et al.**

**Mühlberger et al.**

**Mühlberger et al.**

**Rothbaum et al.**

**Rothbaum et al.**

**Tortella-Feliu et al. (2011)**

**Wiederhold & Wiederhold (2003)**

*Fear of spiders/ cockroaches*  **Bochard et al. (2006)**

**Garcia-Palacios et al. (2002)**

Arachnoph obia

Arachnoph obia

11 Withinsubjects

> Betweensubjects

4 on average

**Sample**

Acrophobia 15 Between-

Acrophobia 10 Within-

*N* **Design No.**

subjects

subjects

**sessions**

**Krijn et al. (2004)** Acrophobia 37 RCT 3 VR administered by HMD and CAVE were

**Krijn et al. (2007)** Acrophobia 26 RCT 4 Self-statements did not additionally enhance

**Krijn et al. (2007)** Aviophobia 59 RCT 4 VR treatment and CBT were equally effective

In contrast, research on the effectiveness of VR in the treatment of *sexual dysfunction* is still in an experimental stage. In one study, VR was integrated into psychodynamic psychotherapy for the treatment of erectile dysfunction and premature ejaculation in *N*= 160 men [12]. VR seemed to help to work through events and associations that were creating the sexual problems. Positive outcomes remained stable after one year follow-up [91].

Furthermore, VR has been used to assess attention impairments in order to diagnose *Attention Deficit Disorder* (ADD). A VR classroom scenario was created, in which children had to perform attention task while being distracted by classroom noises, activities occurring outside the window, or persons passing by [92]. In a clinical trial conducted by the same research group, it was demonstrated that the system could reliably distinguish between children with ADD and healthy controls.

Another virtual environment was developed to treat people with *schizophrenia* [93]. VR scenarios can be individually tailored to simulate patients' hallucinations, such as voices or walls appearing to close in, to teach patients to ignore hallucinations in real life. But even though VR treatment might be an effective adjunct in the treatment of schizophrenics, indications for VR exposure have to be carefully pondered.

The treatment of *addiction* by means of VR seems to be a promising area as well. Similar to exposure therapy in specific phobias, repeatedly showing cues of alcohol or tobacco should lead to extinction of craving. Virtual environments presenting virtual cigarettes [94] or bottles and glasses of alcohol [95] were able to significantly decrease craving.

## **4. Implications for research and therapy**

Hereafter, the findings presented here will be discussed with regard to their implications for research and therapy.

### **4.1. Research**

The studies examining the efficacy of VR treatment in psychotherapy that were conducted up to that point are various with respect to their designs, treatment methods, and results. A multitude of case reports and pilot studies with questionable generalizability were published to demonstrate that VR can be an effective tool in the treatment of mental disorders. To provide a clearer overview of the studies proving the effectiveness of VR in anxiety disorders, the study designs and results of all controlled trials were listed in table 2. All controlled trials that examined the VR or AR treatment of at least one group of participants suffering from an anxiety disorder and that used a standardized outcome measure of anxiety were included. As the table shows, most RTCs have been effected in the field of aviophobia. Particularly with reference to specific phobias, considerable systematic research has been conducted in the past years. However, while the effectiveness of VR and

between children with ADD and healthy controls.

**4. Implications for research and therapy**

research and therapy.

**4.1. Research**

indications for VR exposure have to be carefully pondered.

and negative attitudes towards the body in anorectic patients. A few controlled studies

In contrast, research on the effectiveness of VR in the treatment of *sexual dysfunction* is still in an experimental stage. In one study, VR was integrated into psychodynamic psychotherapy for the treatment of erectile dysfunction and premature ejaculation in *N*= 160 men [12]. VR seemed to help to work through events and associations that were creating the sexual

Furthermore, VR has been used to assess attention impairments in order to diagnose *Attention Deficit Disorder* (ADD). A VR classroom scenario was created, in which children had to perform attention task while being distracted by classroom noises, activities occurring outside the window, or persons passing by [92]. In a clinical trial conducted by the same research group, it was demonstrated that the system could reliably distinguish

Another virtual environment was developed to treat people with *schizophrenia* [93]. VR scenarios can be individually tailored to simulate patients' hallucinations, such as voices or walls appearing to close in, to teach patients to ignore hallucinations in real life. But even though VR treatment might be an effective adjunct in the treatment of schizophrenics,

The treatment of *addiction* by means of VR seems to be a promising area as well. Similar to exposure therapy in specific phobias, repeatedly showing cues of alcohol or tobacco should lead to extinction of craving. Virtual environments presenting virtual cigarettes [94] or

Hereafter, the findings presented here will be discussed with regard to their implications for

The studies examining the efficacy of VR treatment in psychotherapy that were conducted up to that point are various with respect to their designs, treatment methods, and results. A multitude of case reports and pilot studies with questionable generalizability were published to demonstrate that VR can be an effective tool in the treatment of mental disorders. To provide a clearer overview of the studies proving the effectiveness of VR in anxiety disorders, the study designs and results of all controlled trials were listed in table 2. All controlled trials that examined the VR or AR treatment of at least one group of participants suffering from an anxiety disorder and that used a standardized outcome measure of anxiety were included. As the table shows, most RTCs have been effected in the field of aviophobia. Particularly with reference to specific phobias, considerable systematic research has been conducted in the past years. However, while the effectiveness of VR and

bottles and glasses of alcohol [95] were able to significantly decrease craving.

demonstrated the effectiveness of VR in the treatment of eating disorders [88-90].

problems. Positive outcomes remained stable after one year follow-up [91].

Virtual Realities in the Treatment of Mental Disorders: A Review of the Current State of Research 55

**Results**

40 RCT 12 CBT including VR exposure and a panic

11 CBT including VR exposure and CBT

8 max. Interoceptive exposure using VR and

11 CBT including VR exposure and CBT

follow-up

medication

medication

treatment

group

group

group

exposure

veterans

PTSD 11 RCT 10 No significant differences between VR and

PTSD 14 Open trial 20 max. Vietnam veterans showed significant

months follow-up

12 RCT 9 VR treatment and CBT equally reduced the

disorder program were equally effective; results did not stable at 6 months

including exposure in vivo were equally effective in addition to antidepressive

traditional interoceptive therapy equally reduced symptoms; results stable at 3

including exposure in vivo were equally effective in addition to antidepressive

number of panic attacks, the level of depression and state and trait anxiety

significant reductions of re-experiencing, avoidance, and emotional numbing after VR

showed significantly greater improvement on CAPS scores than waitlist control

showed significantly greater improvement on CAPS scores than waitlist control

condition showed significant reduction of depressive and anxiety symptoms in comparison to waitlist control

symptom reductions at 3 and 6 months follow-up; 2 participants experienced an increase in symptoms during VR

present-centered therapy at posttreatment and 6 months follow-up in Vietnam

10 Motor vehicle accident survivors showed

14 Survivors of 9/11 undergoing VR exposure

14 max. Survivors of 9/11 undergoing VR exposure

12 Portuguese war veterans in the VR

**Study Clinical**

**Choi et al. (2005)** Panic

**Penate et al. (2008)**

**Pérez-Ara et al.**

**Vincelli et al. (2003)**

**Difede et al. (2006)**

**Difede et al. (2007)**

**Gamito et al. (2010)**

**Ready et al. (2006)**

**Ready et al. (2010)**

*PTSD*

**Pitti et al. (2008)** Panic

**Beck et al. (2007)** subsyndro

**(2010)**

**Sample**

disorder

Panic disorder

Panic disorder

disorder

Panic disorder

mal PTSD

*N* **Design No.**

27 Matched between subjects

> Betweensubjects

28 Matched betweensubjects

6 Withinsubjects

subjects

experimen tal

subjects

PTSD 17 Between-

PTSD 21 Quasi-

PTSD 10 Between-

**sessions**

Virtual Realities in the Treatment of Mental Disorders: A Review of the Current State of Research 55

54 Virtual Reality in Psychological, Medical and Pedagogical Applications

*N* **Design No.**

10 Withinsubjects

14 Betweensubjects

10 Betweensubjects

> betweensubjects

**sessions**

**Results**

9 Open trial 1 AR treatment significantly reduced

43 RCT 8 VR and in vivo exposure groups showed

8 The combination of VR and anxiety

4 VR treatment reduced self-reported anxiety

months follow-up

36 RCT 12 VR treatment and CBT showed equally

**Price et al. (2011)** Social Phobia 41 RCT 8 Involvement score predicted therapy outcome

avoidance behavior

waitlist control group

avoidance behavior

1 Participants with OCD experienced

healthy controls

months follow-up

37 RCT 9 CBT including VR exposure and CBT

88 RCT 12 CBT as well as VR and CBT combined

12 VR treatment and CBT equally showed

45 RCT 16 VR treatment and combination of CBT and

36 RCT 3 VR treatment including tactile stimulation

was more effective than VR without tactile stimulation; both treatment groups were superior to waitlist control group

participants' fear and avoidance

clinically significant improvement in comparison to waitlist control group

management resulted in reduction of public speaking anxiety on self-report; stable at 3

and physiological reactions significantly in comparison to waitlist control group

significant improvements in anxiety and

VR were both effective in comparison to

significant improvements in anxiety and

resulted in significant improvements of selfrated anxiety and 4 out of 5 anxiety measures in contrast to waitlist control group; results stable at 12 months follow-up

significantly higher anxiety, but also showed a higher decreased ratio of anxiety than

including exposure in vivo resulted in equal symptom reductions in comparison to waitlist control group; results stable at 12

**Sample**

obia, cockroach phobia

Social Phobia

Fear of public speaking

Social Phobia

Social Phobia

Phobia

Fear of public speaking

**Kim et al. (2008)** OCD 63 Matched

Panic disorder

Arachnoph obia

Arachnoph obia

**Study Clinical**

**Juan et al. (2005)** Arachnoph

**Hoffman et al.**

**Michaliszyn (2010)**

*Social Phobia*

**Anderson et al.**

**Harris et al. (2002)**

**Klinger et al. (2005)**

**Robillard et al.**

**Wallach et al. (2009)**

*Panic disorder*  **Botella et al. (2007)**

**Roy et al. (2000)** Social

**(2010)**

*OCD*

**(2003)**

**(2003)**

Virtual Realities in the Treatment of Mental Disorders: A Review of the Current State of Research 57

Another treatment manual was developed by Spira et al. [96]. The authors describe in detail twelve steps to treat combat-related PTDS with the aid of meditation, biofeedback, and VR.Furthermore, Bouchard et al. [98] outlined a treatment manual for VR exposure therapy of specific phobias, can be used with different VR software. In approximately eight sessions, patients are supposed to overcome their fears and stop avoidance behaviors by participating in cognitive restructuring and graduated VR exposure. In addition, guidelines to enhance the sense of presence and minimize potential negative side effects of immersion are provided. However, even though first publications are promising, more evidence-based treatment manuals focusing on specific syndromes are required in order to advance VR

The current state of research presented in this article furnishes considerable evidence for the effectiveness of virtual and augmented environments in the treatment of several mental disorders. However, VR treatment is not yet part of ordinary mental health care. Possible

1. *Costs:* Acquisition of VR equipment is (still) expensive, and training is needed to apply

2. *Reservations against technology:* A myriad of therapists have reservations regarding modern technologies and therefore do not consider using them. German studies demonstrated a relatively high readiness to make use of therapy that integrates text

3. *Limited indications:* VR exposure might be contraindicated in patients with PTSD or comorbid mental disorders. Despite the potential benefits of using modern technologies in psychotherapy, indications with regard to the patient and specific disorder always need to be balanced. In some cases, VR treatment might not be as efficient as conventional therapy.

On the other hand, in the case of obvious indication of VR treatment, therapists should be open with respect to embedding VR technologies into therapy. Those who apply VR in therapy should be aware that VR tools always have to be part of a broader therapy plan and only complement, but cannot replace the skills of well-trained clinicians. Advantages of VR

1. *Cost reduction:* With further technological advancements as well as increased amounts of research on the effectiveness and applicability of VR and AR, technical and financial

1. Sitting on plane, engines off 2. Sitting on plane, engines on

7. Thunderstorm and turbulent flight

usage in psychotherapy.

explanations for that could be:

messages or e-mails, but not VR [99, 100].

costs of those tools will probably be reduced [1].

**5. Conclusion**

VR tools.

treatment include:

3. Taxiing 4. Takeoff 5. Smooth flight 6. Landing

**Table 2.** Overview of VR treatment outcome studies

AR exposure in treating specific phobias seems to be proven, the application of VR in more complex disorders like panic disorder, obsessive-compulsive disorder, and PTSD needs to be further evaluated. Treatment protocols in this field of research are still in an experimental phase and lack controlled studies to prove their effectiveness. In addition, the majority of studies examining the effects of VR-based treatment combines different treatment approaches and therefore makes it difficult to analyze VR outcomes separately. Future research should also work out which groups of patients benefit most from VR and how environments can be adapted to patients' needs. Additionally, comparable outcome measures such as behavioral avoidance tests should be included in future studies. Finally, sample sizes are often too small to generalize study findings and longer-term catemneses are frequently missing.

Alongside the realization of further outcome studies, future research should focus on underlying cognitive and physiological processes of VR exposure. Moreover, the role of the therapist-patient-relationship should be further investigated. Although some studies indicate that the assistance of a therapist might be reduced (e.g. [35]), the consequences of a changing role of the therapist still need to be explored. For instance, the exposure of war veterans to frightening war scenarios might impair trust towards the therapist and therefore influence treatment outcome.

#### **4.2. Therapy**

A significant number of studies has furnished evidence for the effectiveness of using VR in psychotherapy. However, if therapists decide to include VR into treatment sessions, they should act in accordance with certain guidelines in order to abet positive outcomes and minimize negative treatment effects. To date, just a few treatment manuals have been published. For example, Rothbaum et al. [95] presented an abbreviated treatment manual for exposure therapy of acrophobia. VR was used to replace conventional exposure as a component of behavioral therapy. According to the manual, treatment sessions should include symptom assessment, breathing retraining, cognitive restructuring, hyperventilation exposure and VR exposure. The authors recommend arranging VR settings as follows:

*N* **Design No.**

**sessions**

**Rizzo et al. (2009)** PTSD 20 Open trial 10 Participants of "Virtual Iraq" showed

**Reger et al. (2011)** PTSD 24 Open trial 3-12 Significant symptom reduction in Iraq or

AR exposure in treating specific phobias seems to be proven, the application of VR in more complex disorders like panic disorder, obsessive-compulsive disorder, and PTSD needs to be further evaluated. Treatment protocols in this field of research are still in an experimental phase and lack controlled studies to prove their effectiveness. In addition, the majority of studies examining the effects of VR-based treatment combines different treatment approaches and therefore makes it difficult to analyze VR outcomes separately. Future research should also work out which groups of patients benefit most from VR and how environments can be adapted to patients' needs. Additionally, comparable outcome measures such as behavioral avoidance tests should be included in future studies. Finally, sample sizes are often too small to generalize study findings and longer-term catemneses

Alongside the realization of further outcome studies, future research should focus on underlying cognitive and physiological processes of VR exposure. Moreover, the role of the therapist-patient-relationship should be further investigated. Although some studies indicate that the assistance of a therapist might be reduced (e.g. [35]), the consequences of a changing role of the therapist still need to be explored. For instance, the exposure of war veterans to frightening war scenarios might impair trust towards the therapist and therefore

A significant number of studies has furnished evidence for the effectiveness of using VR in psychotherapy. However, if therapists decide to include VR into treatment sessions, they should act in accordance with certain guidelines in order to abet positive outcomes and minimize negative treatment effects. To date, just a few treatment manuals have been published. For example, Rothbaum et al. [95] presented an abbreviated treatment manual for exposure therapy of acrophobia. VR was used to replace conventional exposure as a component of behavioral therapy. According to the manual, treatment sessions should include symptom assessment, breathing retraining, cognitive restructuring, hyperventilation exposure and VR exposure. The authors recommend arranging VR settings as follows:

PTSD 10 Open trial 8-16 Vietnam veterans showed significant

**Results**

clinically and statistically significant

Afghanistan active duty soldiers

not at 6 months follow-up

symptom reductions on the CAPS at 6 months follow-up; self-reported intrusion symptoms were significantly lower at 3 but

symptom reductions

**Sample**

**Table 2.** Overview of VR treatment outcome studies

**Study Clinical**

**Rothbaum et al.**

are frequently missing.

influence treatment outcome.

**4.2. Therapy**

**(2001)**

Another treatment manual was developed by Spira et al. [96]. The authors describe in detail twelve steps to treat combat-related PTDS with the aid of meditation, biofeedback, and VR.Furthermore, Bouchard et al. [98] outlined a treatment manual for VR exposure therapy of specific phobias, can be used with different VR software. In approximately eight sessions, patients are supposed to overcome their fears and stop avoidance behaviors by participating in cognitive restructuring and graduated VR exposure. In addition, guidelines to enhance the sense of presence and minimize potential negative side effects of immersion are provided. However, even though first publications are promising, more evidence-based treatment manuals focusing on specific syndromes are required in order to advance VR usage in psychotherapy.

## **5. Conclusion**

The current state of research presented in this article furnishes considerable evidence for the effectiveness of virtual and augmented environments in the treatment of several mental disorders. However, VR treatment is not yet part of ordinary mental health care. Possible explanations for that could be:

On the other hand, in the case of obvious indication of VR treatment, therapists should be open with respect to embedding VR technologies into therapy. Those who apply VR in therapy should be aware that VR tools always have to be part of a broader therapy plan and only complement, but cannot replace the skills of well-trained clinicians. Advantages of VR treatment include:

1. *Cost reduction:* With further technological advancements as well as increased amounts of research on the effectiveness and applicability of VR and AR, technical and financial costs of those tools will probably be reduced [1].

	- 2. *Lower logistic efforts:* Using VR usually reduces logistic and therefore financial costs in the long term, because no real places have to be accessed in order to expose patients to fear inducing situations.

Virtual Realities in the Treatment of Mental Disorders: A Review of the Current State of Research 59

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## **Author details**

Christiane Eichenberg and Carolin Wolters *University of Cologne, Germany*

## **6. References**

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fear inducing situations.

patient`s needs.

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2): 29–34.

InTech.

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*University of Cologne, Germany*

2. *Lower logistic efforts:* Using VR usually reduces logistic and therefore financial costs in the long term, because no real places have to be accessed in order to expose patients to

3. *Controllability of settings:* Virtual scenes can be easily controlled and adjusted to each

4. *Therapy motivation:* Use of VR might increase therapy motivation, especially in younger patients. For these reasons, integration of virtual environments into day-to-day clinical practice will hopefully be extended in the future. According to a representative survey of the German population [101], 15.7% (*n*= 375) of the respondents would "maybe" make use of VR treatment in case of suffering from a phobia, and 7.4% (*n*= 177) estimated the use of VR as "rather" or "very probable". The results indicated that persons under the age of 35 who were already familiar with modern technologies were most likely to consider VR therapy. It can therefore be concluded that a certain group of the population would take advantage of an expanded offer of VR in psychotherapy.

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**Chapter 3**

© 2012 Stetina et al., licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2012 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

**Games for Health: Have Fun with Virtual Reality!**

"*The beginning of wisdom is the statement 'I do not know.' The person who cannot make that statement is one who will never learn anything. And I have prided myself on my ability to learn*"

Some would not expect a quote like this in a famous and heavily discussed game like "World of Warcraft" ®. And yet, it expresses our novel approach to use virtual realities (VR) in combination with the playful motivating character of digital games for clinicalpsychological learning purposes. Games have a spontaneous quality, a potential for joy and flow, and are characterized by intrinsic motivation. According to our experience, playfulness in psychological intervention can dramatically increase insight processes in patients (e.g. modeling problematic situations with the help of plasticine, building blocks, paper and felt pens etc.). The progress of technology (especially virtual reality) offers possibilities for psychologists of integrating playful elements in virtual reality (serious games). In the present chapter we both, address the potential for psychology originating from the inclusion of technology and discuss problematic aspects of games as well as ethical

There are several definitions of a "game". In general, a game is a system within which players traditionally engage in an artificial conflict, trying to solve a specific problem. A game is defined by rules and measured by a quantifiable outcome (2). According to Jane McGonigal, a game has four key elements: (a) A specific goal that people are willing to work for, (b) rules that stimulate creativity, (c) a feedback system that lets individuals know how they are doing with respect to the goal and (d) voluntary acceptance of the goal, rules, and feedback systems (3). In our opinion, when it is possible to define the rules for a game, it is also possible to create tailor-made games to specifically enhance psychological well-being. The general attributes of playing a game involve spontaneity, intrinsic motivation, defined levels of active engagement and distinction from any other behavior with a make-believe

and reproduction in any medium, provided the original work is properly cited.

Birgit U. Stetina, Anna Felnhofer,

http://dx.doi.org/10.5772/50677

**1. Introduction**

(1).

concerns.

Oswald D. Kothgassner and Mario Lehenbauer

Additional information is available at the end of the chapter

## **Games for Health: Have Fun with Virtual Reality!**

Birgit U. Stetina, Anna Felnhofer, Oswald D. Kothgassner and Mario Lehenbauer

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/50677

#### **1. Introduction**

64 Virtual Reality in Psychological, Medical and Pedagogical Applications

A review of the literature. *Body Image 9*(1): 1-11.

*CyberPsychology and Behavior 3*: 483–501.

477-483.

244.

Realities. Rijeka: InTech.

10.1007/s00278-012-0893-0.

162-70. DOI: 10.1007/s00278-011-0833-4.

*Psychotherapeut.*

Controlled Study. *Cyberpsychology & Behavior 4*: 511-526.

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[90] Riva G, Bacchetta M, Baruffi M, Molinari E (2001) Virtual Reality–Based Multidimensional Therapy for the Treatment of Body Image Disturbances in Obesity: A

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[93] Nowak R. (2002, June 26) VR hallucinations used to treat schizophrenia. *New Scientist*. Retrieved from http://www.newscientist.com/news/news.jsp?id\_ns99992459. [94] Girard B, Turcotte V, Bouchard S, Girard B (2009) Crushing Virtual Cigarettes Reduces Tobacco Addiction and Treatment Discontinuation. *CyberPsychology & Behavior, 12*(5):

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[97] Spira JL, Wiederhold BK, Pyne J, Wiederhold MD (2006). *Virtual Reality Treatment Manual. In Virtuo Physiologically-Faciliated Graded Exposure Therapy in the Treatment of Recently Developed Combat-related PTSD*. San Diego: The Virtual Reality Medical Center. [98] Bouchard S, Robillard G, Larouche S, Loranger C (2012). *Description of a Treatment Manual for In Virtuo Exposure with Specific Phobia.* In: C. Eichenberg (ed.) (2012). Virtual

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classical body image treatment? *CyberPsychology & Behavior, 2*: 149–159.

"*The beginning of wisdom is the statement 'I do not know.' The person who cannot make that statement is one who will never learn anything. And I have prided myself on my ability to learn*" (1).

Some would not expect a quote like this in a famous and heavily discussed game like "World of Warcraft" ®. And yet, it expresses our novel approach to use virtual realities (VR) in combination with the playful motivating character of digital games for clinicalpsychological learning purposes. Games have a spontaneous quality, a potential for joy and flow, and are characterized by intrinsic motivation. According to our experience, playfulness in psychological intervention can dramatically increase insight processes in patients (e.g. modeling problematic situations with the help of plasticine, building blocks, paper and felt pens etc.). The progress of technology (especially virtual reality) offers possibilities for psychologists of integrating playful elements in virtual reality (serious games). In the present chapter we both, address the potential for psychology originating from the inclusion of technology and discuss problematic aspects of games as well as ethical concerns.

There are several definitions of a "game". In general, a game is a system within which players traditionally engage in an artificial conflict, trying to solve a specific problem. A game is defined by rules and measured by a quantifiable outcome (2). According to Jane McGonigal, a game has four key elements: (a) A specific goal that people are willing to work for, (b) rules that stimulate creativity, (c) a feedback system that lets individuals know how they are doing with respect to the goal and (d) voluntary acceptance of the goal, rules, and feedback systems (3). In our opinion, when it is possible to define the rules for a game, it is also possible to create tailor-made games to specifically enhance psychological well-being. The general attributes of playing a game involve spontaneity, intrinsic motivation, defined levels of active engagement and distinction from any other behavior with a make-believe

© 2012 Stetina et al., licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2012 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

quality (4). It is definitely a challenge to combine the motivating and spontaneous quality of a digital game with the characteristics of a psychological intervention.

Games for Health: Have Fun with Virtual Reality! 67

anxiety in most humans and animals. The development of different confrontational methods included gradient confrontation starting with stimuli that are perceived as less dangerous on a subjective scale and proceeding to the more dangerous ones well as non-gradient procedures or flooding, which starts directly with the feared object or situation or animal etc. More recent approaches even include concepts for so called one-session-treatment, as

The traditional way of confrontation is to use imagination, confrontation in sensu, or to use real life situations, confrontation in vivo. Relatively early in media development the question of possible additional forms of confrontation has been asked, e.g. "confrontation in video". Already 2002 an article in the practice oriented German speaking journal "Psychotherapeutische Praxis" has been published that mentions the use of so-called

Virtual reality as an adjunct in psychological practice is not limited to confrontational techniques. Another relevant example is the inclusion of virtual environments in newer therapies of the so called "third wave". That term has been described by Steven Hayes (2004) as description for the mindfulness and acceptance-oriented cognitive behavioral therapies that have already been included in practical work in earlier years (14). All therapies in the third wave have that common goal to undermine destructive, or maladaptive using the traditional term, cognitions, emotions and behaviors. All mentioned therapies include experiments and a lot of training to accomplish the individual goal. As well as for confrontation, exercising in real life using mindfulness or similar concepts is quite complicated because a lot of unpredictable and uncontrollable situations happen in real life. Although of course relevant, because exactly that is the complicated aspect of life for many people, for working on a special skill or awareness is easier if disturbances are reduced.

Listening to the voices of nature around for example is a very powerful and meditative exercise in mindfulness training that can easily be ruined by an emergency helicopter landing near that spot chosen for the exercise. However, virtual environments offer 100% control including the option to simulate unpredictability in certain situations. In addition the virtual environment can easily be enhanced to increase motivation based on individual

That option to increase the motivation by using the technological and psychological possibilities is the "fun part" of working with virtual environments. The work itself is based on group work and a multiprofessional team. Only technological and psychological experts together, including aspects of treatment, design, development, programming and other relevant parts of every virtual environment, are able to develop a motivating game that is effective, includes enough options to generate individual settings based on clinical psychological diagnostic aspects and is motivating enough to actually be fun to play. What is known for children is the same for adolescents. Learning in combination with fun is more effective and guarantees long term changes. Fun in games is based on an interesting storyline, graphics and all other mentioned aspects and many others. Those basic requirements for fun

already show that it is not possible that a single profession is able to create all that.

computer simulations in psychological practice as equivalent method (13).

developed by Oest for specific phobias (12).

preferences of the participant.

Looking at psychological research about digital games over the past years, the main focus is clear. There are more studies about the negative side effects of digital games so far (e.g., addiction, social isolation, violence) than there are regarding the possible advantages of games. Given that in the 1980's the average game player was very young, early studies focused mainly on children and adolescents. Since this population grew older, digital games have become more popular and widespread. For example, the annual reports of the Electronic Entertainment Software Association (ESA) indicate that digital games have become very popular not only for adolescents, but for adults and elder people too. 72% of the American households play computer or video games; the average game player is 37 years old (34 years in 2008) and has been playing games for 12 years. Surprisingly, 29% of gamers were over the age of 50. In general, it is a 25.1 billion dollar industry (5). Another factor is the spread of videogames from playrooms to living rooms with the help of consoles and mobile devices.

At the same time, the percentage of people suffering from psychological disorders dramatically increased. Looking at the economic costs of social phobia, they appear substantial. In western societies, the concurrent estimated costs are 136 million euro per million people (6). These facts build the basis of our research purposes. When digital games are widespread and highly in use, and the need for psychological help is increasing, why not combine both? Psychological research indicates not only negative, but also a lot of positive aspects of playing digital games. There is definitely a need and a market for digital games which are combined with an evidence-based psychological protocol. Looking at peer reviewed publications in general, there is a sudden urge of "health games" research since 2008, attributed to advancements in gaming technology (e.g. Microsoft Kinect® or Nintendo Wii®) as well as the establishment of special conferences (e.g. "Games for Health Conference") (7-9). Unfortunately, so far only a few games for health have undergone a scientific evaluation to validate their effectiveness (10). In the following chapter we discuss positive effects of games for health as well as negative aspects of playing digital games in general. It is highly important to consider negative side effects, such as excessive gaming behavior as well as social isolation before integrating digital games into therapy. At the end of the chapter, we also address ethical aspects of research in gaming environments and integrating new media into psychological intervention.

## **2. The "fun part"**

Exposition is a very powerful technique of confrontation with an anxiety or phobia related stimulus in cognitive behavioral therapy (CBT). This technique has already been used in the middle of the 20th century by behavior therapists and was afterwards adopted by cognitive pioneers such as Aaron Beck, describing the cognitive and behavioral rationale for example in one of his books 1979 (11). Early behavioral experiments showed that direct confrontation with phobic stimuli (without avoidance) leads to habituation and a substantial decrease in anxiety in most humans and animals. The development of different confrontational methods included gradient confrontation starting with stimuli that are perceived as less dangerous on a subjective scale and proceeding to the more dangerous ones well as non-gradient procedures or flooding, which starts directly with the feared object or situation or animal etc. More recent approaches even include concepts for so called one-session-treatment, as developed by Oest for specific phobias (12).

66 Virtual Reality in Psychological, Medical and Pedagogical Applications

integrating new media into psychological intervention.

and mobile devices.

**2. The "fun part"**

a digital game with the characteristics of a psychological intervention.

quality (4). It is definitely a challenge to combine the motivating and spontaneous quality of

Looking at psychological research about digital games over the past years, the main focus is clear. There are more studies about the negative side effects of digital games so far (e.g., addiction, social isolation, violence) than there are regarding the possible advantages of games. Given that in the 1980's the average game player was very young, early studies focused mainly on children and adolescents. Since this population grew older, digital games have become more popular and widespread. For example, the annual reports of the Electronic Entertainment Software Association (ESA) indicate that digital games have become very popular not only for adolescents, but for adults and elder people too. 72% of the American households play computer or video games; the average game player is 37 years old (34 years in 2008) and has been playing games for 12 years. Surprisingly, 29% of gamers were over the age of 50. In general, it is a 25.1 billion dollar industry (5). Another factor is the spread of videogames from playrooms to living rooms with the help of consoles

At the same time, the percentage of people suffering from psychological disorders dramatically increased. Looking at the economic costs of social phobia, they appear substantial. In western societies, the concurrent estimated costs are 136 million euro per million people (6). These facts build the basis of our research purposes. When digital games are widespread and highly in use, and the need for psychological help is increasing, why not combine both? Psychological research indicates not only negative, but also a lot of positive aspects of playing digital games. There is definitely a need and a market for digital games which are combined with an evidence-based psychological protocol. Looking at peer reviewed publications in general, there is a sudden urge of "health games" research since 2008, attributed to advancements in gaming technology (e.g. Microsoft Kinect® or Nintendo Wii®) as well as the establishment of special conferences (e.g. "Games for Health Conference") (7-9). Unfortunately, so far only a few games for health have undergone a scientific evaluation to validate their effectiveness (10). In the following chapter we discuss positive effects of games for health as well as negative aspects of playing digital games in general. It is highly important to consider negative side effects, such as excessive gaming behavior as well as social isolation before integrating digital games into therapy. At the end of the chapter, we also address ethical aspects of research in gaming environments and

Exposition is a very powerful technique of confrontation with an anxiety or phobia related stimulus in cognitive behavioral therapy (CBT). This technique has already been used in the middle of the 20th century by behavior therapists and was afterwards adopted by cognitive pioneers such as Aaron Beck, describing the cognitive and behavioral rationale for example in one of his books 1979 (11). Early behavioral experiments showed that direct confrontation with phobic stimuli (without avoidance) leads to habituation and a substantial decrease in The traditional way of confrontation is to use imagination, confrontation in sensu, or to use real life situations, confrontation in vivo. Relatively early in media development the question of possible additional forms of confrontation has been asked, e.g. "confrontation in video". Already 2002 an article in the practice oriented German speaking journal "Psychotherapeutische Praxis" has been published that mentions the use of so-called computer simulations in psychological practice as equivalent method (13).

Virtual reality as an adjunct in psychological practice is not limited to confrontational techniques. Another relevant example is the inclusion of virtual environments in newer therapies of the so called "third wave". That term has been described by Steven Hayes (2004) as description for the mindfulness and acceptance-oriented cognitive behavioral therapies that have already been included in practical work in earlier years (14). All therapies in the third wave have that common goal to undermine destructive, or maladaptive using the traditional term, cognitions, emotions and behaviors. All mentioned therapies include experiments and a lot of training to accomplish the individual goal. As well as for confrontation, exercising in real life using mindfulness or similar concepts is quite complicated because a lot of unpredictable and uncontrollable situations happen in real life. Although of course relevant, because exactly that is the complicated aspect of life for many people, for working on a special skill or awareness is easier if disturbances are reduced.

Listening to the voices of nature around for example is a very powerful and meditative exercise in mindfulness training that can easily be ruined by an emergency helicopter landing near that spot chosen for the exercise. However, virtual environments offer 100% control including the option to simulate unpredictability in certain situations. In addition the virtual environment can easily be enhanced to increase motivation based on individual preferences of the participant.

That option to increase the motivation by using the technological and psychological possibilities is the "fun part" of working with virtual environments. The work itself is based on group work and a multiprofessional team. Only technological and psychological experts together, including aspects of treatment, design, development, programming and other relevant parts of every virtual environment, are able to develop a motivating game that is effective, includes enough options to generate individual settings based on clinical psychological diagnostic aspects and is motivating enough to actually be fun to play. What is known for children is the same for adolescents. Learning in combination with fun is more effective and guarantees long term changes. Fun in games is based on an interesting storyline, graphics and all other mentioned aspects and many others. Those basic requirements for fun already show that it is not possible that a single profession is able to create all that.

It is definitely a challenge to combine VR with the motivational character of games. Although games are an essential part of all known human cultures, the impact has grown over the past decades. Games for health offer a novel multidisciplinary working approach for psychologists, game designers and computer scientists, but they should solely concentrate on the player experience (15). We do not believe that psychologists can be game designers and vice versa, we need a strong interdisciplinary cooperation to focus on the player's needs. Psychologists can be advocates for players, providing fundamental knowledge about the impact of games, the side-effects and – last but not least – elements of therapy. Game designers provide creativity, inspiration and a motivational immersing player experience.

Games for Health: Have Fun with Virtual Reality! 69

maladaptive behavior of problematic computer gaming. An analysis of the studies over the past years reveals that some core criteria seem to be relevant over conceptual frameworks and might therefore have an especially high relevance for operationalization (a) withdrawal symptoms, (b) relapse/loss of control, (c) tolerance, (d) preoccupation, (e) negative consequences and (f) mood modification (19-21). Some authors suggested that the elements such as mood change, tolerance and cognitive (and not behavioral!) preoccupation should be explained better by using the term "highly engaged gamers", because the players show merely symptoms according to a high level of interest in the given activities. Therefore, it makes sense to distinguish between an "addictive" and an "engaged" behavior (20). There are significant differences between highly engaged players and "addicted" players, with highly engaged players often mistaken as addicted. "Addicted" players spend significantly more time playing MMORPGs, and there are more negative consequences in their lives (resulting in poorer quality of life), in comparison to highly engaged players. Therefore it

Beyond these discussions about terms and definitions of problematic behavior in computer games, recent research as in (16) indicates that there are differences between several game types regarding problematic computer gaming behavior and psychopathology. Especially "Massively Multiplayer Online Role Playing Games" (MMORPGs) are one of the game types which are often associated with problematic behavior. Especially the social elements of MMORPGs lead to addictive behavior (23, 24). Other computer game types, such as realtime strategy games and ego-shooters, are less linked to problematic computer game

The general stereotype of a gamer is that he or she is socially isolated and sitting alone in front of a computer. Several studies succeeded in revealing the contrary. For example, some found MMORPG players not to be socially isolated, instead interacting in real time with other players to gain goals and achievements and in order to survive (25). MMORPGs require a certain level of social skills; unsocial behavior is not accepted in most guilds of MMORPGs such as World of Warcraft®. Yet, this observation is not limited to MMORPGs only. The majority of recent Ego-Shooters and Real-Time Strategy Games are also playable online with the possibility or exigency to interact with others (26). Studies show that playing computer games for reasons like relieving loneliness or escaping from everyday life problems leads to problematic behaviors mentioned as the first negative aspect (16, 27).

Another common stereotype, especially communicated by mass media, is that the average game player is aggressive and violent. Indeed, many popular computer games on the market include explicit violent and aggressive content. Usually, playing these games is associated with real life aggression. A meta-analytic review seems to support this opinion (28). Moreover, several current studies revealed that virtual violence may lead to

makes sense to distinguish between these two types of gamers (20, 22).

behavior as a form of a behavioral addiction.

**3.2. Social isolation of gamers**

**3.3. Violence in computer games**

## **3. Side effects of playing digital games**

Before speaking about side effects or problems that might occur with intensive or even dependent gaming behavior, an underlying methodological aspect has to be pointed out strongly. Although common knowledge, we tend to forget that the coexistence of two phenomena has nothing to do with causality. Even if we would find that gamers in general suffer significantly more often from psychological disorders than the general population, (besides the fact that there is no evidence that we could ever calculate a result in that direction) we would not be allowed to conclude that they are showing more psychological disorders because of gaming. Concluding the opposite; that people with psychological disorders are more likely to start gaming than the general population, is not acceptable as well.

In addition to the problem of causality an entire group of other methodological aspects that go along with gaming research has not been mentioned yet. Hence, a short discussion about other critical research aspects is included in the chapter about ethical aspects.

As mentioned above, most research studies concentrated on the negative side effects of playing digital games over the last years. In general, the perception of gamers in mass media is that they are highly addictive, that games can lead to social isolation or evoke depressive tendencies, and promote violence or cause aggressive behavior. As discussed the methodology of such findings has to be analyzed in depth before any conclusions can be drawn.

Yet, some studies indeed show negative aspects of using online games as mentioned above, such as problematic computer gaming behavior (16), social isolation (17), and aggressive tendencies of computer gamers (18). However, contrasting findings as in (19) exist as well, which suggest that the common stereotypes of online gamers are wrong.

#### **3.1. Problematic computer gaming**

Although widely and inflationary used, there is a huge lack of conceptualization in the concepts of "pathological computer gaming" or "computer game addiction". Several definitions, criteria and descriptive symptoms make it very difficult to characterize the maladaptive behavior of problematic computer gaming. An analysis of the studies over the past years reveals that some core criteria seem to be relevant over conceptual frameworks and might therefore have an especially high relevance for operationalization (a) withdrawal symptoms, (b) relapse/loss of control, (c) tolerance, (d) preoccupation, (e) negative consequences and (f) mood modification (19-21). Some authors suggested that the elements such as mood change, tolerance and cognitive (and not behavioral!) preoccupation should be explained better by using the term "highly engaged gamers", because the players show merely symptoms according to a high level of interest in the given activities. Therefore, it makes sense to distinguish between an "addictive" and an "engaged" behavior (20). There are significant differences between highly engaged players and "addicted" players, with highly engaged players often mistaken as addicted. "Addicted" players spend significantly more time playing MMORPGs, and there are more negative consequences in their lives (resulting in poorer quality of life), in comparison to highly engaged players. Therefore it makes sense to distinguish between these two types of gamers (20, 22).

Beyond these discussions about terms and definitions of problematic behavior in computer games, recent research as in (16) indicates that there are differences between several game types regarding problematic computer gaming behavior and psychopathology. Especially "Massively Multiplayer Online Role Playing Games" (MMORPGs) are one of the game types which are often associated with problematic behavior. Especially the social elements of MMORPGs lead to addictive behavior (23, 24). Other computer game types, such as realtime strategy games and ego-shooters, are less linked to problematic computer game behavior as a form of a behavioral addiction.

#### **3.2. Social isolation of gamers**

68 Virtual Reality in Psychological, Medical and Pedagogical Applications

**3. Side effects of playing digital games**

player experience.

well.

drawn.

It is definitely a challenge to combine VR with the motivational character of games. Although games are an essential part of all known human cultures, the impact has grown over the past decades. Games for health offer a novel multidisciplinary working approach for psychologists, game designers and computer scientists, but they should solely concentrate on the player experience (15). We do not believe that psychologists can be game designers and vice versa, we need a strong interdisciplinary cooperation to focus on the player's needs. Psychologists can be advocates for players, providing fundamental knowledge about the impact of games, the side-effects and – last but not least – elements of therapy. Game designers provide creativity, inspiration and a motivational immersing

Before speaking about side effects or problems that might occur with intensive or even dependent gaming behavior, an underlying methodological aspect has to be pointed out strongly. Although common knowledge, we tend to forget that the coexistence of two phenomena has nothing to do with causality. Even if we would find that gamers in general suffer significantly more often from psychological disorders than the general population, (besides the fact that there is no evidence that we could ever calculate a result in that direction) we would not be allowed to conclude that they are showing more psychological disorders because of gaming. Concluding the opposite; that people with psychological disorders are more likely to start gaming than the general population, is not acceptable as

In addition to the problem of causality an entire group of other methodological aspects that go along with gaming research has not been mentioned yet. Hence, a short discussion about

As mentioned above, most research studies concentrated on the negative side effects of playing digital games over the last years. In general, the perception of gamers in mass media is that they are highly addictive, that games can lead to social isolation or evoke depressive tendencies, and promote violence or cause aggressive behavior. As discussed the methodology of such findings has to be analyzed in depth before any conclusions can be

Yet, some studies indeed show negative aspects of using online games as mentioned above, such as problematic computer gaming behavior (16), social isolation (17), and aggressive tendencies of computer gamers (18). However, contrasting findings as in (19) exist as well,

Although widely and inflationary used, there is a huge lack of conceptualization in the concepts of "pathological computer gaming" or "computer game addiction". Several definitions, criteria and descriptive symptoms make it very difficult to characterize the

other critical research aspects is included in the chapter about ethical aspects.

which suggest that the common stereotypes of online gamers are wrong.

**3.1. Problematic computer gaming**

The general stereotype of a gamer is that he or she is socially isolated and sitting alone in front of a computer. Several studies succeeded in revealing the contrary. For example, some found MMORPG players not to be socially isolated, instead interacting in real time with other players to gain goals and achievements and in order to survive (25). MMORPGs require a certain level of social skills; unsocial behavior is not accepted in most guilds of MMORPGs such as World of Warcraft®. Yet, this observation is not limited to MMORPGs only. The majority of recent Ego-Shooters and Real-Time Strategy Games are also playable online with the possibility or exigency to interact with others (26). Studies show that playing computer games for reasons like relieving loneliness or escaping from everyday life problems leads to problematic behaviors mentioned as the first negative aspect (16, 27).

#### **3.3. Violence in computer games**

Another common stereotype, especially communicated by mass media, is that the average game player is aggressive and violent. Indeed, many popular computer games on the market include explicit violent and aggressive content. Usually, playing these games is associated with real life aggression. A meta-analytic review seems to support this opinion (28). Moreover, several current studies revealed that virtual violence may lead to

desensitization in real life, partly confirming these assumptions using fMRI (29). These studies show that the act of killing virtually is connected with a decreasing potential in regions of the brain which are associated with empathy. Nevertheless, the impact of computer games with violent content on aggressive behavior should be discussed very critically. In fact, there is no clear evidence about the causality. We do not know whether games cause aggressive behavior, or players with aggressive behavior tend to buy games with violent elements. This would ignore the possibilities that people with higher trait aggression play violent games, or players discover this negative emotion of aggression in a controlled environment to explore their own self (30).

Games for Health: Have Fun with Virtual Reality! 71

based on CBT. CBT is the so called goldstandard when it comes to treatment of phobias (39). Usually, exposition in CBT treatment can be performed in vivo or in sensu. We propose a third approach "in virtu", demonstrating similar effects to in vivo or in sensu (33, 39-41). Garcia-Palacios and colleagues state that most patients suffering from phobias prefer VR over in vivo therapy (41). Accordingly, Piercey and colleagues find that the presentation of spiders in VR produces significantly increased skin conductance responses in arachnophobic patients, who perceive the virtual surrounding as "real" (39). In general, these results suggest that the use of technology in therapy can dramatically enhance insight

Moreover, VR can be well combined with the motivating character of (serious) games. They offer plenty of varieties of social interaction with other users or non-playing characters/avatars. Almost any real life situation can be displayed in VR. Gaming in general is perceived by many gamers as a positive emotional experience, with positive effects on emotional health. Stress and psychophysiological arousal are important triggers and maintaining factors when it comes to the aetiology of many psychological disorders. Tailormade games provide innovative ways for health improvements using stress management methods (4). The biggest impact of games with psychological intervention purposes is the potential to increase motivation through a mechanism that is usually activated in games within the context of play. There is a certain trend in the last years, most studies focus on the outcomes of exercise and rehab games and the games concentrate on physical activity and nutrition (7). So called "exergames" are interactive video games combined with exercise and movement. Exergames such as interactive dance videogames are very popular among adolescents; they can cause an increase in heart rate and physical expenditure. In their study of "Dance Dance Revolution", Maloney and colleagues found potential to use exergames to boost physical activity among overweight and obese adolescents. There was a significant improvement of physical activity in a treatment group (12 weeks of playing "Dance Dance

The use of videogame consoles as an analgesia treatment alternative has been studied at the Burn Center of New York Presbyterian Hospital (43). Most burn injury patients feel an intense amount of pain as the body repairs itself, together with extreme anxiety. These factors can lead to less commitment to medical exercise regimens, resulting in limitations in movement. Nurses often play videos or music to distract burn patients from pain. In the last years this treatment has been combined with VR environments such as "Snow-World", a virtual reality set in cold surroundings like the Arctic to distract burn recovery patients from pain (44). Video game consoles work on similar premises. Nintendo Wii ® is a popular console with motion sensors; it allows modulating therapeutic environments as well as the duration of the exercise. Although it is difficult because of the diversity of burn patients to devise standard treatment protocols, the authors conclude in general that the potential of digital games as analgesia is enormous. Burn injury patients can use a defined set of physical games, the gaming system records the progress and the movements of the player and sends the data automatically to a therapist, who is able to adjust the therapy according to the progress (43). Yohannan and colleagues state that burn

Revolution"), compared to a decrease in a control group (42).

processes (36).

## **4. Positive effects of virtual reality and digital games**

While some researchers focus on the negative effects of computer games such as the aforementioned "game addiction" or violent behaviour, we emphasize the positive aspects of VR and digital games. Literature suggests, that with the appropriate design and use, digital games have the potential to be very effective psychotherapeutic tools (31). Technology is changing the psychologist-patient relationship in every way, and helps to provide visual and auditory stimuli that are difficult to generate in real life settings. Psychologists are able to create new VR environments in which patients can engage during a therapy. To date, the effectiveness of VR in therapy is investigated in the treatment of anxiety disorders, phobias, addiction, depression and attention-deficit hyperactivity disorder (ADHD) as well as a tool for stress management (31).

Usually patients interact in VR with the help of peripheral devices, such as head-mounted displays and keyboards. The effects of virtual exposure to flight, heights and social settings are well studied (32, 33). They can be more cost and time effective for both therapists and patients, thereby improving the accessibility of therapy to individuals who may previously have been unable to afford treatment. Over the past decades, with the spread of new technologies (e.g. Internet, video game consoles, mobile devices) in households across various social classes, psychologists tried to integrate VR to provide low-threshold, efficacious and less time-intensive interventions (34). For example, VR combined with biofeedback (BFB) is a scientifically proven method that includes technological feedback to provide body relaxation. Decreased anxiety and physiological arousal have been demonstrated in patients who gained insights into their physical arousal immediately on a computer monitor and who consequently learned to control their bodily functions. In general, there is an estimated savings of \$540 – \$630 per client when new technology is integrated in therapy (34, 35). Furthermore, a variety of research has been conducted on technology-aided interventions such as online-based self-administered interventions, and promising results concerning anxiety and stress reduction have been reported (36). Selfadministered treatment programs provide cognitive-behavioural therapy (CBT) with minimal therapist support, but effective outcomes (37, 38). These programs lack game plays and reward systems, they are not games per definition. However, these studies provide answers to the crucial basic research question, if technology-aided interventions are successful at all. VR has been used successfully for the treatment of phobias, using protocols based on CBT. CBT is the so called goldstandard when it comes to treatment of phobias (39). Usually, exposition in CBT treatment can be performed in vivo or in sensu. We propose a third approach "in virtu", demonstrating similar effects to in vivo or in sensu (33, 39-41). Garcia-Palacios and colleagues state that most patients suffering from phobias prefer VR over in vivo therapy (41). Accordingly, Piercey and colleagues find that the presentation of spiders in VR produces significantly increased skin conductance responses in arachnophobic patients, who perceive the virtual surrounding as "real" (39). In general, these results suggest that the use of technology in therapy can dramatically enhance insight processes (36).

70 Virtual Reality in Psychological, Medical and Pedagogical Applications

controlled environment to explore their own self (30).

**4. Positive effects of virtual reality and digital games**

disorder (ADHD) as well as a tool for stress management (31).

desensitization in real life, partly confirming these assumptions using fMRI (29). These studies show that the act of killing virtually is connected with a decreasing potential in regions of the brain which are associated with empathy. Nevertheless, the impact of computer games with violent content on aggressive behavior should be discussed very critically. In fact, there is no clear evidence about the causality. We do not know whether games cause aggressive behavior, or players with aggressive behavior tend to buy games with violent elements. This would ignore the possibilities that people with higher trait aggression play violent games, or players discover this negative emotion of aggression in a

While some researchers focus on the negative effects of computer games such as the aforementioned "game addiction" or violent behaviour, we emphasize the positive aspects of VR and digital games. Literature suggests, that with the appropriate design and use, digital games have the potential to be very effective psychotherapeutic tools (31). Technology is changing the psychologist-patient relationship in every way, and helps to provide visual and auditory stimuli that are difficult to generate in real life settings. Psychologists are able to create new VR environments in which patients can engage during a therapy. To date, the effectiveness of VR in therapy is investigated in the treatment of anxiety disorders, phobias, addiction, depression and attention-deficit hyperactivity

Usually patients interact in VR with the help of peripheral devices, such as head-mounted displays and keyboards. The effects of virtual exposure to flight, heights and social settings are well studied (32, 33). They can be more cost and time effective for both therapists and patients, thereby improving the accessibility of therapy to individuals who may previously have been unable to afford treatment. Over the past decades, with the spread of new technologies (e.g. Internet, video game consoles, mobile devices) in households across various social classes, psychologists tried to integrate VR to provide low-threshold, efficacious and less time-intensive interventions (34). For example, VR combined with biofeedback (BFB) is a scientifically proven method that includes technological feedback to provide body relaxation. Decreased anxiety and physiological arousal have been demonstrated in patients who gained insights into their physical arousal immediately on a computer monitor and who consequently learned to control their bodily functions. In general, there is an estimated savings of \$540 – \$630 per client when new technology is integrated in therapy (34, 35). Furthermore, a variety of research has been conducted on technology-aided interventions such as online-based self-administered interventions, and promising results concerning anxiety and stress reduction have been reported (36). Selfadministered treatment programs provide cognitive-behavioural therapy (CBT) with minimal therapist support, but effective outcomes (37, 38). These programs lack game plays and reward systems, they are not games per definition. However, these studies provide answers to the crucial basic research question, if technology-aided interventions are successful at all. VR has been used successfully for the treatment of phobias, using protocols Moreover, VR can be well combined with the motivating character of (serious) games. They offer plenty of varieties of social interaction with other users or non-playing characters/avatars. Almost any real life situation can be displayed in VR. Gaming in general is perceived by many gamers as a positive emotional experience, with positive effects on emotional health. Stress and psychophysiological arousal are important triggers and maintaining factors when it comes to the aetiology of many psychological disorders. Tailormade games provide innovative ways for health improvements using stress management methods (4). The biggest impact of games with psychological intervention purposes is the potential to increase motivation through a mechanism that is usually activated in games within the context of play. There is a certain trend in the last years, most studies focus on the outcomes of exercise and rehab games and the games concentrate on physical activity and nutrition (7). So called "exergames" are interactive video games combined with exercise and movement. Exergames such as interactive dance videogames are very popular among adolescents; they can cause an increase in heart rate and physical expenditure. In their study of "Dance Dance Revolution", Maloney and colleagues found potential to use exergames to boost physical activity among overweight and obese adolescents. There was a significant improvement of physical activity in a treatment group (12 weeks of playing "Dance Dance Revolution"), compared to a decrease in a control group (42).

The use of videogame consoles as an analgesia treatment alternative has been studied at the Burn Center of New York Presbyterian Hospital (43). Most burn injury patients feel an intense amount of pain as the body repairs itself, together with extreme anxiety. These factors can lead to less commitment to medical exercise regimens, resulting in limitations in movement. Nurses often play videos or music to distract burn patients from pain. In the last years this treatment has been combined with VR environments such as "Snow-World", a virtual reality set in cold surroundings like the Arctic to distract burn recovery patients from pain (44). Video game consoles work on similar premises. Nintendo Wii ® is a popular console with motion sensors; it allows modulating therapeutic environments as well as the duration of the exercise. Although it is difficult because of the diversity of burn patients to devise standard treatment protocols, the authors conclude in general that the potential of digital games as analgesia is enormous. Burn injury patients can use a defined set of physical games, the gaming system records the progress and the movements of the player and sends the data automatically to a therapist, who is able to adjust the therapy according to the progress (43). Yohannan and colleagues state that burn

patients can benefit therapeutically from videogames. In their case study a burn patient performed better after a game treatment over two weeks in terms of reaction time and maximum excursion than conventional therapy alone. The functional mobility increased faster, there was more motivation for the therapy when game-based interventions were included (45).

Games for Health: Have Fun with Virtual Reality! 73

In light of manifold possible applications of technology in therapy and research, there is a discussion about related ethical principles and their field of scope. Research in virtual environments should follow all "standard" ethical principles and has to take the special setting into consideration. Interestingly especially qualitative researchers have dealt with

We suppose that the same ethical principles, which pertain to conventional psychological treatment and therapy, should also be applied in technology-aided psychological treatment (53). The manifold risks psychologists are confronted with as well as the ethical dilemmas that may arise from the adoption of technology in the realms of treatment, may be significantly different from those encountered in conventional face-to-face counseling psychology. In online-based communication, psychologists are confronted with the same probability of encountering distressing information (e.g. a suicidal attempt of a client), yet online-therapists are a lot less likely to fully apprehend the severity of this attempt if not being confronted with the patient face-to-face (54). Furthermore, absolute certainty about a client's true identity is difficult to be achieved in digital settings. It seems that these facts make it more difficult to provide effective treatment (55).Last but not least, it is necessary to consider negative side effects of digital games, as pointed out above. We believe that we can't create digital games with a specific psychological protocol, even if evidence-based and studied before, and leave the patients alone. There has to be a certain level of guidance from a psychologist. It is necessary to consider these facts to engage in a discussion about implementing new, even more specific guidelines for technology-assisted therapy. Ethical guidelines regarding the use of VR and digital games are scarce at best. To date only few mental health organizations respectively psychologists' associations have issued specific

ethical aspects of researching gaming environments over the last years (51, 52).

regulations, most of which pertain to online-counseling or e-therapy (56).

To date, the American Psychological Association or the European Federation of Psychologists' Associations lack specific regulations. On the other hand, specialized organizations such as the International Society for Mental Health Online (ISMHO) or the American Mental Health Counselors Association (AMHCA) stress the importance of taking into account basic ethical principles like beneficence, nonmaleficence, autonomy and confidentiality when implementing any sort of technology-assisted training. Only then, ethically sound treatment of patients can be ensured. First of all, in terms of beneficence and nonmaleficence, it has to be ensured "that clients are intellectually, emotionally, and physically capable of using technology-assisted counseling services, and of understanding the potential risks and/or limitations of such services" (57). For example, some minor groups of people who never had any contact with technology (e.g., a personal computer) or elderly people may feel intimidated by VR or digital games and may not accept them as tools for psychological treatment. Compliance may be hampered for this group of clients. Additionally, there are some mental disorders for which specific technology based treatments are not recommended. Because of their immanent difficulties of separating reality from fiction, it is argued that VR can have negative side effects for some

**5. Ethical challenges**

Some studies focus on games especially for older people. This is no surprise given the fact, that the average game player is 37 years old, and an estimated 29% of the gamers are over 50 years old (5). Older people can benefit from digital games as well; they have a positive impact on their health condition and improve their capability to carry on activities in their everyday life. The key factors of an interest in games for health are challenge, socialization, escape from a daily routine and fun. Focus groups stated that they would use specifically designed digital games on a daily basis (46). VR and digital games provide the opportunity to support the independence of older people. Especially in rural areas, where distance makes it inconvenient for older people to access adequate health services, technology can provide easier possibilities to measure the health status. In their narrative review, Marston and Smith identified several possibilities of using technology for older people. Commercially available game consoles, such as Sony Playstation with EyeToy ® or Microsoft Kinect ® make it easier to provide older people with exergames for rehabilitation purposes (47). Several studies report a positive outcome when it comes to fall prevention and stroke rehabilitation. Especially Nintendo Wii ® facilitates wrist rehabilitation by specifically designed programs (with the possibility to add joint therapies for knees or elbows) (48). In general, the results are promising. The use of games for health (both off-theshelf or specially designed for rehabilitation purposes) can have a dramatically increasing effect of the physical abilities of older people (47).

Contrary to studies about exergames, there are only limited studies about games especially for psychological health. One example is "SPARX", an online role-playing game for the treatment of depression (http://sparx.org.nz), based on a CBT protocol. The player can choose an avatar and undertake a series of challenges in a virtual fantasy world. The main goal of the game is to restore a balance of "Gloomy Negative Automatic Thoughts". There are seven modules (e.g., psychoeducation about depression, activity scheduling and behavioral action, dealing with emotions, problem solving, cognitive restructuring and relapse prevention) over 5 weeks available. Intervention studies revealed promising effects. There were significant decreases of depression scores, compared to a waiting-list condition. "SPARX" seems to be an innovative and effective game-based treatment for students with symptoms of depression (49). Another study examined the effects of an online-based self-administered social skills training with playful elements, especially for shy students. This online-training consist of 14 text-based lessons, combined with playful elements such as "identifying negative automatic thoughts" with the help of a drag-anddrop game. Lehenbauer and colleagues revealed significant effects of this training, a highly significant increase of social skills as well as a highly significant decrease of social fears in the intervention group, with no results in a control group undergoing no intervention (8, 50).

#### **5. Ethical challenges**

72 Virtual Reality in Psychological, Medical and Pedagogical Applications

effect of the physical abilities of older people (47).

intervention (8, 50).

included (45).

patients can benefit therapeutically from videogames. In their case study a burn patient performed better after a game treatment over two weeks in terms of reaction time and maximum excursion than conventional therapy alone. The functional mobility increased faster, there was more motivation for the therapy when game-based interventions were

Some studies focus on games especially for older people. This is no surprise given the fact, that the average game player is 37 years old, and an estimated 29% of the gamers are over 50 years old (5). Older people can benefit from digital games as well; they have a positive impact on their health condition and improve their capability to carry on activities in their everyday life. The key factors of an interest in games for health are challenge, socialization, escape from a daily routine and fun. Focus groups stated that they would use specifically designed digital games on a daily basis (46). VR and digital games provide the opportunity to support the independence of older people. Especially in rural areas, where distance makes it inconvenient for older people to access adequate health services, technology can provide easier possibilities to measure the health status. In their narrative review, Marston and Smith identified several possibilities of using technology for older people. Commercially available game consoles, such as Sony Playstation with EyeToy ® or Microsoft Kinect ® make it easier to provide older people with exergames for rehabilitation purposes (47). Several studies report a positive outcome when it comes to fall prevention and stroke rehabilitation. Especially Nintendo Wii ® facilitates wrist rehabilitation by specifically designed programs (with the possibility to add joint therapies for knees or elbows) (48). In general, the results are promising. The use of games for health (both off-theshelf or specially designed for rehabilitation purposes) can have a dramatically increasing

Contrary to studies about exergames, there are only limited studies about games especially for psychological health. One example is "SPARX", an online role-playing game for the treatment of depression (http://sparx.org.nz), based on a CBT protocol. The player can choose an avatar and undertake a series of challenges in a virtual fantasy world. The main goal of the game is to restore a balance of "Gloomy Negative Automatic Thoughts". There are seven modules (e.g., psychoeducation about depression, activity scheduling and behavioral action, dealing with emotions, problem solving, cognitive restructuring and relapse prevention) over 5 weeks available. Intervention studies revealed promising effects. There were significant decreases of depression scores, compared to a waiting-list condition. "SPARX" seems to be an innovative and effective game-based treatment for students with symptoms of depression (49). Another study examined the effects of an online-based self-administered social skills training with playful elements, especially for shy students. This online-training consist of 14 text-based lessons, combined with playful elements such as "identifying negative automatic thoughts" with the help of a drag-anddrop game. Lehenbauer and colleagues revealed significant effects of this training, a highly significant increase of social skills as well as a highly significant decrease of social fears in the intervention group, with no results in a control group undergoing no In light of manifold possible applications of technology in therapy and research, there is a discussion about related ethical principles and their field of scope. Research in virtual environments should follow all "standard" ethical principles and has to take the special setting into consideration. Interestingly especially qualitative researchers have dealt with ethical aspects of researching gaming environments over the last years (51, 52).

We suppose that the same ethical principles, which pertain to conventional psychological treatment and therapy, should also be applied in technology-aided psychological treatment (53). The manifold risks psychologists are confronted with as well as the ethical dilemmas that may arise from the adoption of technology in the realms of treatment, may be significantly different from those encountered in conventional face-to-face counseling psychology. In online-based communication, psychologists are confronted with the same probability of encountering distressing information (e.g. a suicidal attempt of a client), yet online-therapists are a lot less likely to fully apprehend the severity of this attempt if not being confronted with the patient face-to-face (54). Furthermore, absolute certainty about a client's true identity is difficult to be achieved in digital settings. It seems that these facts make it more difficult to provide effective treatment (55).Last but not least, it is necessary to consider negative side effects of digital games, as pointed out above. We believe that we can't create digital games with a specific psychological protocol, even if evidence-based and studied before, and leave the patients alone. There has to be a certain level of guidance from a psychologist. It is necessary to consider these facts to engage in a discussion about implementing new, even more specific guidelines for technology-assisted therapy. Ethical guidelines regarding the use of VR and digital games are scarce at best. To date only few mental health organizations respectively psychologists' associations have issued specific regulations, most of which pertain to online-counseling or e-therapy (56).

To date, the American Psychological Association or the European Federation of Psychologists' Associations lack specific regulations. On the other hand, specialized organizations such as the International Society for Mental Health Online (ISMHO) or the American Mental Health Counselors Association (AMHCA) stress the importance of taking into account basic ethical principles like beneficence, nonmaleficence, autonomy and confidentiality when implementing any sort of technology-assisted training. Only then, ethically sound treatment of patients can be ensured. First of all, in terms of beneficence and nonmaleficence, it has to be ensured "that clients are intellectually, emotionally, and physically capable of using technology-assisted counseling services, and of understanding the potential risks and/or limitations of such services" (57). For example, some minor groups of people who never had any contact with technology (e.g., a personal computer) or elderly people may feel intimidated by VR or digital games and may not accept them as tools for psychological treatment. Compliance may be hampered for this group of clients. Additionally, there are some mental disorders for which specific technology based treatments are not recommended. Because of their immanent difficulties of separating reality from fiction, it is argued that VR can have negative side effects for some

schizophrenic and psychotic patients (55). Patients in crisis situations as well as borderline patients, who are even in a greater need of face-to-face interaction than an average patient should not be treated exclusively via the Internet or using solely VR-applications.

Games for Health: Have Fun with Virtual Reality! 75

more enforced to consider possible harm as well as potential that may arise from VR usage

Interestingly the focus of research on gaming has been relatively narrow in direction of problematic behaviour in combination with gaming. In relation the developmental side has been more or less neglected by some research groups. But especially experts on gaming behaviour are equipped with knowledge and skills that would enhance the development of

The development of interventions is mostly based on cognitive behavioural theories in psychology and psychotherapy. As these theories are based on well known learning research the fun aspect of games for health has been identified to be a core aspect for efficiency. To create fun in a virtual environment a game character of an intervention is the number one option. Good game design is difficult to achieve and not possible for psychologists. Multiprofessional teams and respectful interaction in those teams are needed to create an effective intervention with the mentioned fun aspect. In addition new fields are opening for computer scientists as well as for psychologists. Job opportunities are going to include less traditional positions. Psychologists might grow to be more developers and designers of interventions that are used with only limited help afterwards. Computer scientists might increase their focus on human-technique interaction and psychological aspects of technology. Both professions need to develop a sense of interdisciplinary work

Ethical considerations in the development of virtual environments have to be discussed with different professions and the intended target group. Of course the side effects need to be considered as well, and extensive differential diagnostics in clinical psychology are a prerequisite for participants as long as research was not able to show clear directions in

A very relevant question that needs to be discussed for the future ist the availability of the developed and evaluated interventions. Who is going to be allowed to buy VR interventions? Based on open source ideas and the powerful empowerment aspect of knowledge free distribution is a very appealing way. A number of problematic thoughts are related with free distribution, amongst other aspects the following points have to be considered: (a) subjective value of the system: some theories suggest that free help is valued less or considered as not effective as help one has to pay for. (b) Use for other as the intended purposes. (c) Efforts of the developing team and their value system. (d) self help systems as an option or different modes (well known from self help guides with

We state that there is definitely more research needed to draw a clear picture of positive outcomes of games for health. Most studies in this area often included trials with small sample sizes, only a few include large scale trials. Some studies also lack explicit exclusion

and transfer them into comprehensible, internationally applicable ethical guidelines.

**6. Conclusion**

interventions.

causal relations.

and different viewpoints of the same phenomenon.

supplements for professionals – or the other way round).

We emphasize that special focus has to be put on the informed consent process when intending to use technology or conducting treatment via technological applications. Patients have the right to be fully informed about the potentials and the limitations of any technology such as the circumstances under which it can or cannot be applied to the patients' situation (58). Patients have to be provided with the information about what data is being collected about them when using the technology. They should furthermore be informed about the location it is stored at and about how long it is intended to remain there. To mitigate breaches of confidentiality, all measures have to be taken by the treating psychologist to ensure secure data storage no matter what kind of data is collected (e.g. physiological measures when using biofeedback). When providing Internet based services, psychologists should utilize secure web sites, firewalls and encrypting programs (56). In order to avoid any harm to patients, psychologists should possess adequate expertise concerning the technology they apply. In terms of serious games for health, this includes knowledge about maladaptive gaming behavior as well as any other negative side effects. Psychologists are to assure that their treatment method is in no violation of local laws or ethical regulations such as professional membership organizations (57).