CYBERPSYCHOLOGY & BEHAVIOR

Volume 6, Number 4, 2003

© Mary Ann Liebert, Inc.

The VEPSY UPDATED Project: Clinical Rationale and

Technical Approach

G. RIVA, Ph.D.,1, 2 M. ALCÃNIZ,3 L. ANOLLI, Ph.D.,2 M. BACCHETTA, Psy.D.,1

R. BAÑOS, Ph.D.,9 C. BUSELLI, M.S.,10 F. BELTRAME, Ph.D.,4 C. BOTELLA, Ph.D.,5
G. CASTELNUOVO, M.S.,1 G. CESA, M.S.,1 S. CONTI, M.S.,1 C. GALIMBERTI, Ph.D.,2
L. GAMBERINI, Ph.D.,11 A. GAGGIOLI, M.S.,1 E. KLINGER, Ph.D.,7, P. LEGERON, M.D.,13
F. MANTOVANI, Ph.D.,1,2 G. MANTOVANI, Ph.D.11 E. MOLINARI, Ph.D.,2–6
G. OPTALE, M.D.,8 L. RICCIARDIELLO, M.S.12 C. PERPIÑÁ, Ph.D.,9 S. ROY, Psy.D.,13
A. SPAGNOLLI, Ph.D.,11 R. TROIANI, M.S.,14 and C. WEDDLE, M.S.15

ABSTRACT

More than 10 years ago, Tart (1990) described virtual reality (VR) as a technological model of
consciousness offering intriguing possibilities for developing diagnostic, inductive, psy-
chotherapeutic, and training techniques that can extend and supplement current ones. To ex-
ploit and understand this potential is the overall goal of the “Telemedicine and Portable
Virtual Environment in Clinical Psychology”—VEPSY UPDATED—a European Community–
funded research project (IST-2000-25323, www.cybertherapy.info). Particularly, its specific
goal is the development of different PC-based virtual reality modules to be used in clinical
assessment and treatment of social phobia, panic disorders, male sexual disorders, obesity,
and eating disorders. The paper describes the clinical and technical rationale behind the clin-
ical applications developed by the project. Moreover, the paper focuses its analysis on the
possible role of VR in clinical psychology and how it can be used for therapeutic change.

INTRODUCTION developing diagnostic, inductive, psychotherapeu-

tic, and training techniques that can extend and

M ORE THAN 10 YEARS AGO, Tart1 described vir-

tual reality (VR)—for the first time in a psy-
chological journal—as a technological model of
supplement current ones.”
In fact, VR offers a blend of attractive attributes
for psychologists. The most basic of these is its abil-
consciousness offering “intriguing possibilities for ity to create a three dimensional (3D) simulation of

1Applied Technology for Neuro-Psychology Lab., Istituto Auxologico Italiano, Verbania, Italy.
2Department of Psychology, Catholic University, Milan, Italy.
3MedIClab-Universidad Politécnica de Valencia, Valencia, Spain.

4DIST, University of Genoa, Genoa, Italy.

5Universitat Jaume I, Castellon de la Plana, Spain.

6Laboratorio Sperimentale di Psicologia, Istituto Auxologico Italiano, Verbania, Italy.

7GREYC, Université de Caen, Caen, France.

8Associazione Medici Psicoterapeuti, Venice, Italy.

9Universidad de Valencia, Valencia, Spain.

10ELSAG, Genoa, Italy.

11Department of General Psychology, University of Padua, Padua, Italy.

12TSD Projects, Milan, Italy.

13Unité de Thérapie Comportementale et Cognitive, Hôpital Sainte-Anne, Paris, France.

14VRHealth, Milan, Italy.

15PREVI, Valencia, Italy.

433
434 RIVA ET AL.

reality that can be explored by patients. VR can be in vivo exposure. Another advantage of VR is the
considered a special, sheltered setting where pa- possibility of carrying out exposure to bodily sen-
tients can start to explore and act without feeling sations (interoceptive) and situational exposure si-
threatened. In this sense, the virtual experience is multaneously. Traditionally, exposure for panic
an “empowering environment” that therapy pro- disorder involves exposure to agoraphobic situations
vides for patients.2 As noted by Botella and col- and interoceptive exposure that are performed in
leagues,3 nothing the patients fear can “really” different sessions. VR allows the exposure of the
happen to them in VR. With such assurance, they patient to an agoraphobic situation (i.e., a train)
can freely explore, experiment, feel, live, and expe- and, simultaneously, can elicit bodily sensations
rience feelings and/or thoughts. VR thus becomes through visual or sound effects (blurry vision,
a very useful intermediate step between the thera- pounding heart, etc). In different controlled stud-
pist and the real world. ies, VRE was as effective as in vivo therapy in the
Even though various therapists have been using treatment of acrophobia,4,5 spider phobia,6 and fear
VR in their clinical practice since the early 1990s, of flying. 7–10
more work is still required. To exploit and under- The second clinical focus of the VEPSY Updated
stand this potential is the overall goal of the project was the treatment of male sexual distur-
“Telemedicine and Portable Virtual Environment in bances. In particular, Optale and his team11,12 used
Clinical Psychology”—VEPSY UPDATED—a Euro- immersive VR to improve the efficacy of a psychody-
pean Community–funded research project (IST- namic approach in treating male erectile disorders.
2000-25323, www.cybertherapy.info) whose specific In the proposed VE, four different expandable
goal is the development of different PC-based vir- pathways open up through a forest, bringing the
tual reality modules to be used in clinical assessment patients back into their childhood, adolescence,
and treatment of social phobia, panic disorders, and teens when they started to get interested in the
male sexual disorders, obesity, and eating disorders. opposite sex. Different situations are presented
The paper describes the clinical and technical ra- with obstacles that the patient had to overcome to
tionale behind the clinical applications developed go on. VR environments are here used as a form of
by the project. Specifically, the paper focuses its controlled “dreams” allowing the patient to ex-
analysis on the possible role of VR in clinical psy- press in a nonverbal way transference reactions
chology and how it can be used for therapeutic and free associations related to the ontogenetic de-
change. velopment of male sexual identity. General princi-
ples of psychological dynamisms such as the
difficulty with separations and ambivalent attach-
VEPSY UPDATED: ments are used to inform interpretive efforts. The
THE CLINICAL RATIONALE obtained results—30 out of 36 patients with psy-
chological erectile dysfunction and 28 out of 37 pa-
Until now, the most common application of VR tients with premature ejaculation maintained
in clinical psychology has been the treatment of partial or complete positive response after 6-month
phobias. The VEPSY Updated project, too, ad- follow-up—show that VR seems to hasten the heal-
dressed phobias. The Spanish group headed by ing process and reduce dropouts. Moreover, Optale
Cristina Botella focused on the treatment of panic used PET scans to analyze regional brain metabo-
disorder and agoraphobia, while the French clinical lism changes from baseline to follow-up in patients
group headed by Patrick Legeron addressed the treated with VR.13 The analysis of the scans showed
treatment of social phobia. different metabolic changes in specific areas of the
The overall rationale shared by the two groups is brain connected with the erection mechanism, sug-
very simple: in VR the patient is intentionally con- gesting that this method accelerated the healing
fronted with the feared stimuli while allowing the process by reopening old brain pathways or con-
anxiety to attenuate. Because avoiding a dreaded solidating them. The results also suggest that new
situation reinforces all phobias, each exposure to it mnemonic associations and rarely used inter-
actually lessens the anxiety through the processes synaptic connections, characterized by a particular
of habituation and extinction. magnitude of activation may be established, favor-
The use of VR exposure (VRE) offers a number of ing satisfaction of natural drives.12
advantages over in vivo or imaginal exposure: it can The third part of the project focuses on obesity and
be administered in traditional therapeutic settings eating disorders. Particularly, Riva and his clinical
and it is more controlled and cost-effective than group, led by Bacchetta and Molinari,14,15 are using
VEPSY UPDATED PROJECT: CLINICAL RATIONALE AND TECHNICAL APPROACH 435

Experiential Cognitive Therapy (ECT), an integrated associative writing regarding a problematic body
approach ranging from cognitive-behavioral therapy part, stage performance, or psychodrama.24,25
to VR sessions, in the treatment of eating disorders
and obesity. In this approach, VR is mainly used to Unfortunately, both approaches, even if effective
modify body image perceptions. in the long term, require a strong involvement of
What is the rationale behind this approach? Dif- the patient and many months of treatment.
ferent studies show that body image dissatisfaction The use of VR offers two key advantages: (1) It is
can be considered a form of cognitive bias.16,17 The possible to integrate all different methods (cogni-
essence of this cognitive perspective is that the cen- tive, behavioral and experiential) commonly used
tral psychopathological concerns of an individual in the treatment of body experience disturbances
bias the manner in which information is processed. within a single virtual experience. (2) VR can be
Usually, this biased information processing occurs used to induce in the patient a controlled sensory
automatically. Also, it is generally presumed that rearrangement that unconsciously modifies his/
the process occurs almost outside the person’s her bodily awareness (body schema). When we use
awareness unless the person consciously reflects a virtual reality system we feel our self-image pro-
upon his or her thought processes (as in cognitive jected onto the image of the visual cues (i.e., a cer-
therapy). tain figure or an abstract point, such as cursors,
According to Williamson and colleagues,16 body which moves in accordance with the movement of
size overestimation can be considered as a complex our own hand) appearing in the video monitor, as a
judgment bias, strictly linked to attentional and part of or an extension of our own hands.26 As
memory biases for body-related information: “If in- noted by Iriki and colleagues,27 “Essential elements
formation related to body is selectively processed of such an image of our own body should be com-
and recalled more easily, it is apparent how the self- prised of neural representations about the dimen-
schema becomes so highly associated with body- sion, posture and movement of the corresponding
related information . . . If the memories related to body parts in relation to the environmental space.
body are also associated with negative emotion, ac- Thus, its production requires integration of so-
tivation of negative emotion should sensitize the matosensory (intrinsic) and visual (extrinsic) infor-
person to body-related stimuli causing even greater mation of our own body in space.” When this
body size overestimation.” happens, the information itself becomes accessible
It is very difficult to counter a cognitive bias. In at a conscious level 28 and can be modified more
fact, biased information processing occurs auto- easily.
matically and the subjects are unaware about it. In a case study a 22-year-old female university
So, for them, the biased information is real. They student diagnosed with anorexia nervosa was sub-
cannot distinguish between perceptions and bi- mitted to ECT treatment.29 At the end of the in-
ased cognitions. Moreover, any attempt for con- patient treatment, the subject increased her bodily
vincing them is usually useless and sometimes awareness joined to a reduction in her level of body
produce a strong emotional defense. In fact, the dissatisfaction. Moreover, the patient presented a
denial of the disorder and resistance to treatment high degree of motivation to change. Expanding
are two of the most vexing clinical problems in these results, they carried different clinical trials on
these pathologies.18,19 female patients30–33: 25 patients suffering from
Given these difficulties there are only two dif- binge-eating disorders were in the first study, 20 in
ferent approaches to the treatment of body image the second, and 18 obese in the third. At the end of
disturbances17: the inpatient treatments, the patients in both sam-
ples modified significantly their bodily awareness.
• Cognitive-behavioral strategies. This approach is This modification was associated to a reduction in
based on assessment, education, exposure and problematic eating and social behaviors.
modification of body image. The therapy both
identify and challenge appearance assump-
tions, and modify self-defeating body image THE TECHNICAL APPROACH
behaviors.20–22
• Feminist approach. Feminist’s therapists usually use To produce the VR applications used in its clini-
experiential techniques, such as guided imagery, cal trials, the VEPSY Updated project used PC
movement exercises, and art and dance ther- based VR platforms. The following paragraphs
apy.23,24 Other experiential techniques include free- both describe the rationale behind this choice and
436 RIVA ET AL.

detail the technical characteristics of the VR plat- • Pentium IV/Athlon XP desktop VR system:
form chosen by the project. 2000 mhz or better
256 mega RAM or better
Minimum specification for the graphic engine:
The emergence of PC-based virtual reality
ATI Radeon 9000 64MB VRam or Nvidia
Even if the history of VR is based on expensive GeForce 4 440MX 640Mb VRam
graphic workstations, the significant advances in • Pentium IV/Athlon based portable VR system:
PC hardware that have been made over the last 1500 mhz or better
three years, are allowing the appearance of low cost 128 mega RAM or better
VR systems. While the cost of a basic desktop VR Minimum specification for the graphic engine:
system has not changed much, the functionality ATI Radeon 9000 16Mb VRam or Nvidia
has improved dramatically, both in terms of graph- GeForce 4 Go 32Mb VRam
ics processing power and VR hardware such as
head-mounted displays (HMDs). The availability The hardware also includes:
of powerful PC engines based on Intel’s Pentium
IV, AMD’s Athlon and Motorola’s Power PC G4, • A head-mounted display (HMD) subsystem. The
and the emergence of reasonably priced 3D acceler- HMDs used are as follows:
ator cards allow high-end PCs to process and dis- Glasstron PLM-A35/PLM-S700 from Sony Inc
play 3D simulations in real time. (www.sel.sony.com/SEL/). The Glasstron uses
A standard Celeron/Duron 2 Ghz system with as LCD technology (two 0.7Í active matrix color
little as 128 Mb of RAM can offer sufficient processing LCD’s) displaying 180000 pixels (PLM-A35:
power for a bare-bone VR simulation, a 2.5 Ghz Pen- 800 H 2 225 V) or 520000 pixels (PLM-S700:
tium III//Athlon with 256 Mb of RAM, can provide a 832 H 2 624 V) to each eye. Sony has designed
convincing virtual environment, while a dual 3 Ghz its Glasstron so that no optical adjustment at
Pentium IV XEON configuration with OpenGL accel- all is needed, aside from tightening a two
eration, 512 Mb of RAM and 128/256 Mb of VRAM ratchet knobs to adjust for the size of the
running on Windows XP Professional, can match the wearer’s head. There’s enough “eye relief”
horsepower of a graphics workstation.34 (distance from the eye to the nearest lens) that
Immersion is also becoming more affordable. For it’s possible to wear glasses under the HMD.
example, it is possible to have a basic HMD with gy- The motion tracking is provided by Intersense
roscopic head tracking for less than $1200 and has through its InterTrax 30 serial gyroscopic
built in. For instance, Olympus (Japan) distributes tracker (azimuth, ±180 degrees; elevation, ±80
its basic video headset for about $600 without head degrees; refresh rate, 256 Hz; latency time, 38
tracking. Two years ago HMDs of the same quality msec ± 2).
were about 10 times more costly. A HMD with VGA VFX-3D from Interactive Imaging Systems Inc.
quality and 3D video produced by a Korean manu- (www.iisvr.com). The VFX-3D uses LCD tech-
facturer is now about $2,500. However, this price nology (two 0.7Í active matrix color LCD’s)
will probably decrease during the next five years. displaying 360,000 pixels (800 H 2 400 V) to
Presently, input devices for desktop VR are each eye. The HMD doesn’t require any optical
largely mouse- and joystick-based. Although these adjustment. It can be easily worn using the
devices are not suitable for all applications, they patented flip-up visor. Included is also an ac-
can keep costs down and avoid the ergonomic is- celerometer based serial tracker (pitch and roll
sues of some of the up-to-date I/O devices such as sensitivity, 6 70 degrees 6 ~0.1 degrees; yaw
3D mouses and gloves. Also, software has been sensitivity, 360 degrees 6 0.1 degrees)
greatly improved over the last 3 years. It now al- • A two-button joystick-type input device. This will
lows users to create or import 3D objects, to apply provide an easy way of motion: pressing the
behavioral attributes such as weight and gravity to upper button the operator moves forward, press-
the objects, and to program the objects to respond ing the lower button the operator moves back-
to the user via visual and/or audio events. wards. The direction of the movement is given
by the rotation of operator’s head.
VEPSY UPDATED: the hardware
To ensure the broadest user base, all the VR
All the VR-based clinical modules were devel- modules have been developed as a shared
oped to be used on the following PC platforms: telemedicine tool available through the Internet
VEPSY UPDATED PROJECT: CLINICAL RATIONALE AND TECHNICAL APPROACH 437

by using a plug-in for the most common CONCLUSION

browsers (Explorer and Navigator) and as porta-
ble tools based on Speed-Step notebook PCs How is it possible to change a patient? Even if this
(Pentium IV/Duron, 16MB VRam and 256 Mb question has many possible answers according to
Ram). This choice ensures wide availability, an the specific psychotherapeutic approach, generally
open architecture, and the possibility of benefit- change comes through an intense focus on a partic-
ing from the improvements planned for these ular instance or experience. 35 Within this general
machines by INTEL and AMD (i.e., faster proces- model we have the insight-based approach of psy-
sors and enhanced multimedia support). Both so- choanalysis, the schema-reorganization goals of
lutions allow the support of end-users in their cognitive therapy, the functional analysis of behav-
living environment. ioral activation, the interpersonal relationship focus
of the interpersonal therapy, or the enhancement of
experience awareness in experiential therapies.
What are the differences between them? Accord-
VEPSY UPDATED: the software
ing to Safran and Greenberg,36 behind the specific
Each module was created by using the software therapeutic approach we can find two different
Virtools Dev. 2.0 (www.virtools.com). Based on a models of change: bottom-up and top-down.
building-block, object-oriented paradigm, Virtools Bottom-up processing begins with a specific emo-
makes interactive environments and characters by tional experience and leads eventually, to change at
importing geometry and animation from several the behavioral and conceptual level, whereas top-
animation packages, including Discreet 3D Studio down change usually involves exploring and chal-
MAX (www.discreet.com), Alias Wavefront Maya lenging tacit rules and beliefs that guide the
(www.aliaswavefront.com), Softimage (www. processing of emotional experience and the behav-
softimage.com), and Nichimen Nendo and Mirai ioral planning. These two models of change are fo-
(www.nichimen.com), and combining them with cused on two different cognitive systems, one for
an array of more than 200 basic behaviors. By drag- information transmission (top-down) and one for
ging and dropping the behavior blocks together the conscious experience (bottom-up), both of which
user can combine them to create complex interac- may process sensory input. 37 The existence of two
tive behaviors. different cognitive systems is clearly showed by the
The Virtools toolset consists of Virtools Cre- dissociation between verbal knowledge and task
ation, the production package that constructs in- performance: people learn to control dynamic sys-
teractive content using behavior blocks; Virtools tems without being able to specify the relations
Player, the freely distributable viewer that allows within the system, and they can sometimes de-
anyone to see the 3D content; Virtools Web Player, scribe the rules by which the system operates with-
a plug-in version of the regular player for out being able to put them into practice.
Netscape Navigator and Microsoft Internet Ex- Even if many therapeutic approaches are based on
plorer; and the Virtools Dev for developers who just one of the two change models, a therapist usu-
create custom behaviors or combine Virtools with ally requires both.35 Some patients seem to operate
outside technology. Virtools Dev includes a full- primarily by top-down information processing,
blown software development kit (Virtools SDK) which may then prime the way for corrective emo-
for the C++ developer that comes with code sam- tional experiences. For others the appropriate access
ples and an ActiveX player which can be used to point is the intensification of their emotional experi-
play Virtools content in applications developed ence and their awareness of both it and related
with tools such as Frontpage, Visual Basic or Vi- behaviors. Finally, different patients who initially en-
sual C++. gage the therapeutic work only through top-down
Content created with Virtools can be targeted at processing, may able later in the therapy to make use
the stand-alone Virtools Player, at web pages of bottom-up emotional processing. In this situation,
through the Virtools Web Player, at Macromedia a critical advantage can be provided by VR.
Director, or at any product that supports ActiveX. VR can be considered a sophisticated communi-
Alternatively, the Virtools SDK allows the user cation interface.38 Even if the three applications de-
to turn content into stand-alone executable files. veloped by the VEPSY Updated project have a very
Virtools’s rendering engine supports DirectX, different rationale, all use VR as a communication
OpenGL, Glide and software rendering, although interface, able to collect and integrate different
hardware acceleration is recommended. inputs and data sets in a single real-like experience.
438 RIVA ET AL.

Using it accordingly, is possible to target a specific proach. Dissociation Progress in the Dissociative Disor-
cognitive or emotional system without any signifi- ders 3:222–233.
cant change in the therapeutic approach. For in- 2. Riva, G., & Wiederhold, B.K. (2002). Introduction to
stance, behavioral therapists may use a VE for the special issue on virtual reality environments in
behavioral sciences. IEEE Transactions on Information
activating the fear structure in a phobic patient
Technology in Biomedicine 6:193–197.
through confrontation with the feared stimuli; a
3. Botella, C., Perpiña, C., Baños, R.M., et al. (1998). Vir-
cognitive therapist may use VR situations to assess tual reality: a new clinical setting lab. Studies in
situational memories or disrupt habitual patterns of Health Technology and Informatics 58:73–81.
selective attention; experiential therapists may use 4. Emmelkamp, P.M., Bruynzeel, M., Drost, L., et al.
VR to isolate the patient from the external world (2001). Virtual reality treatment in acrophobia: a
and help him/her in practicing the right actions; comparison with exposure in vivo. Cyberpsychology
psychodynamic therapists may use VEs as complex & Behavior 4:335–339.
symbolic systems for evoking and releasing affect. 5. Emmelkamp, P.M., Krijn, M., Hulsbosch, A.M., et al.
In fact, one of the main results of the VEPSY Up- (2002). Virtual reality treatment versus exposure in
dated project was the use of VR as an advanced vivo: a comparative evaluation in acrophobia. Behav-
iour Research & Therapy 40:509–516.
imaginal system: an experiential form of imagery
6. Garcia-Palacios, A., Hoffman, H., Carlin, A., et al.
located between imagination and reality39–41 that
(2002). Virtual reality in the treatment of spider pho-
can be used to help the patient in differentiate be- bia: a controlled study. Behavior Research and Therapy
tween perception and cognition. As noted by Glantz 40:983–993.
and colleagues42: “one reason it is so difficult to get 7. Rothbaum, B.O., Hodges, L., Smith, S., et al. (2000). A
people to update their assumptions is that change controlled study of virtual reality exposure therapy
often requires a prior step—recognizing the distinc- for the fear of flying. Journal of Consulting & Clinical
tion between an assumption and a perception. Until Psychology 68:1020–1026.
revealed to be fallacious, assumptions constitute the 8. Rothbaum, B.O., Hodges, L., Anderson, P.L., et al.
world; they seem like perceptions, and as long as (2002). Twelve-month follow-up of virtual reality and
they do, they are resistant to change.” Using the standard exposure therapies for the fear of flying.
Journal of Consulting & Clinical Psychology 70:428–432.
sense of presence induced by VR, the therapist can
9. Wiederhold, B.K., Jang, D.P., Gevirtz, R.G., et al.
actually demonstrate to the patient that what looks
(2002). The treatment of fear of flying: a controlled
like a perception doesn’t really exist. Once this has study of imaginal and virtual reality graded expo-
been understood, individual maladaptive assump- sure therapy. IEEE Transactions on Information Tech-
tions can then be challenged more easily. nology in Biomedicine 6:218–223.
However, significant efforts are still required to 10. Maltby, N., Kirsch, I., Mayers, M., et al. (2002). Vir-
move VR into routine clinical use. Clearly, building tual Reality Exposure Therapy for the treatment of
new and additional virtual environments—possibly fear of flying: A controlled investigation. Journal of
networked and integrated in portable devices such as Consulting & Clinical Psychology 70:1112–1118
PDAs or cellular phones—is important so therapists 11. Optale, G., Munari, A., Nasta, A., et al. (1997). Multi-
will continue to investigate applying these tools in media and virtual reality techniques in the treatment
of male erectile disorders. International Journal of Im-
their day-to-day clinical practice.43 In fact, in most cir-
potence Research 9:197–203.
cumstances, the clinical skills of the therapist remain
12. Optale, G., Chierichetti, F., Munari, A., et al. (1999).
the key factor in the successful use of VR systems. PET supports the hypothesized existence of a male
sexual brain algorithm which may respond to treat-
ment combining psychotherapy with virtual reality.
ACKNOWLEDGMENTS Studies in Health Technology and Informatics 62:249–251.
13. Optale, G., Chierichetti, F., Munari, A., et al. (1998).
The present work was supported by the Com- Brain PET confirms the effectiveness of VR treatment
mission of the European Communities (CEC), spe- of impotence. International Journal of Impotence Re-
cifically by the IST programme through the VEPSY search 10:45.
14. Riva, G., Bacchetta, M., Baruffi, M., et al. (1998). Ex-
UPDATED (IST-2000–25323) research project
periential cognitive therapy: a VR-based approach
(www.cybertherapy.info).
for the assessment and treatment of eating disorders.
In: G. Riva, B. Wiederhold, E. Molinari (eds.), Virtual
environments in clinical psychology and neuroscience:
REFERENCES Methods and techniques in advanced patient-therapist in-
teraction. Amsterdam: IOS Press, pp. 120–135.
1. Tart, C.T. (1990). Multiple personality, altered states 15. Riva, G., Bacchetta, M., Cesa, G., et al. (2001). Virtual
and virtual reality: the world simulation process ap- reality and telemedicine based experiential cognitive
VEPSY UPDATED PROJECT: CLINICAL RATIONALE AND TECHNICAL APPROACH 439

herapy: rationale and clinical protocol. In: G. Riva, C. 31. Riva, G., Bacchetta, M., Baruffi, M., et al. (2000). Vir-
Galimberti (eds.), Towards CyberPsychology: mind, tual reality environment for body image modifica-
Cognition and Society in the Internet Age. Amsterdam: tion: A multidimensional therapy for the treatment
IOS Press, pp. 273–308. of body image in obesity and related pathologies. Cy-
16. Williamson, D.A. (1996). Body image disturbance in berpsychology & Behavior 3:421–431.
eating disorders: a form of cognitive bias. Eating Dis- 32. Riva, G., Bacchetta, M., Baruffi, M., et al. (2001). Virtual
orders 4:47–58. reality-based multidimensional therapy for the treat-
17. Thompson, J.K., Heinberg, L.J., Altabe, M., et al. ment of body image disturbances in obesity: a con-
(1999). Exacting beauty: Theory, assessment and treat- trolled study. CyberPsychology and Behavior 4:511–526.
ment of body image disturbance. Washington, DC: 33. Riva, G., Bacchetta, M., Baruffi, M., et al. (2002).
American Psychological Association. Virtual-reality-based multidimensional therapy for
18. Vitousek, K.B., & Orimoto, L. (1993). Cognitive- the treatment of body image disturbances in binge
behavioral models of anorexia nervosa, bulimia ner- eating disorders: a preliminary controlled study.
vosa, and obesity. In: K.S. Dobsob, P.C. Kendall IEEE Transactions on Information Technology in Biomed-
(eds.), Psychopathology and cognition. San Diego (CA): icine 6:224–234.
Academic Press, pp. 34. Riva, G. (2002). Virtual reality for health care: the sta-
19. Vitousek, K.B., Watson, S., & Wilson G.T. (1998). En- tus of research. Cyberpsychology & Behavior 5:219–225.
hancing motivation for change in treatment-resistant 35. Wolfe, B.E. (2002). The Role of Lived Experience in
eating disorders. Clinical Psychology Review 18:391–420. Self- and Relational Observation: A Commentary on
20. Cash, T.F. (1995). What do you see when you look in the Horowitz (2002). Journal of Psychotherapy Integration
mirror? Helping yourself to a positive body image. New 12:147–153.
York: Bantam Books. 36. Safran, J.D., & Greenberg, L.S. (1991). Emotion, psy-
21. Cash, T.F. (1997). The body image workbook: an eight- chotherapy, and change. New York: The Guilford Press.
step program for learning to like your looks. Oakland, 37. Brewin, C.R. (1989). Cognitive Change Processes in
CA: New Harbinger. Psychotherapy. Psychological Review 96:379–394.
22. Rosen, J.C. (1996). Improving body image in obesity. 38. Riva, G., Molinari, E., & Vincelli, F. (2002). Interac-
In: J.K. Thompson (ed.), Body image, eating disorders tion and presence in the clinical relationship: virtual
and obesity. Washington, DC: APA—American Psy- reality (VR) as communicative medium between pa-
chological Association, pp. 425–440. tient and therapist. IEEE Transactions on Information
23. Wooley, S.C., & Wooley, O.W. (1985). Intensive out- Technology in Biomedicine 6:198–205.
patient and residential tratment for bulimia. In: D.M. 39. North, M.M., North, S.M., & Coble, J.R. (1997). Vir-
Garner, P.E. Garfinkel (eds.), Handbook of psychother- tual reality therapy for fear of flying. American Jour-
apy for anorexia and bulimia. New York: Guilford nal of Psychiatry 154:130.
Press, pp. 120–132. 40. Vincelli, F. (1999). From imagination to virtual real-
24. Wooley, S.C. (1995). Feminist influences on the treat- ity: the future of clinical psychology. Cyberpsychology
ment of eating disorders. In: K.D. Brownell, C.G. & Behavior 2:241–248.
Fairburn (eds.), Eating disorders and obesity: a compre- 41. Vincelli, F., Molinari, E., & Riva, G. (2001). Virtual
hensive handbook. New York: Guilford, pp. 294–298. reality as clinical tool: immersion and three-
25. Kearney-Cooke, A., & Striegel-Moore, R. (1994). dimensionality in the relationship between patient
Treatment of childhood sexual abuse in anorexia ner- and therapist. Studies in Health Technology and Infor-
vosa and bulimia nervosa: A feminist psychody- matics 81:551–553.
namic approach. International Journal of Eating 42. Glantz, K., Durlach, N.I., Barnett, R.C., et al. (1997).
Disorders 15:305–319. Virtual reality (VR) and psychotherapy: Opportuni-
26. James, K.H., Humphrey, G.K., & Goodale, M.A. ties and challenges. Presence, Teleoperators, and Virtual
(2001). Manipulating and recognizing virtual objects: Environments 6:87–105
where the action is. Canadian Journal of Experimental 43. Riva, G., Wiederhold, B., & Molinari, E. (eds.). (1998).
Psychology 55:111–120. Virtual environments in clinical psychology and neuro-
27. Iriki, A., Tanaka, M., Obayashi, S., et al. (2001). Self- science: Methods and techniques in advanced patient–
images in the video monitor coded by monkey intra- therapist interaction. Amsterdam: IOS Press. Available:
parietal neurons. Neuroscience Research 40:163–173. www.cybertherapy.info/pages/book2.htm.
28. Baars, B.J. (1988). A cognitive theory of consciousness.
New York: Cambridge University Press.
29. Riva, G., Bacchetta, M., Baruffi, M., et al. (1999). Vir- Address reprint requests to:
tual reality based experiential cognitive treatment of Giuseppe Riva, Ph.D.
anorexia nervosa. Journal of Behavioral Therapy and
Università Cattolica del Sacro Cuore
Experimental Psychiatry 30:221–230.
Largo Gemelli 1
30. Riva, G., Bacchetta, M., Baruffi, M., et al. (2000). Vir-
tual reality-based experiential cognitive treatment of 20123 Milan, Italy
obesity and binge-eating disorders. Clinical Psychol-
ogy and Psychotherapy 7:209–219. E-mail: [email protected]