Persuasive virtual agents for peer pressure simulations in Immersive Virtual Reality:Designing for trainings in people with mild to borderline intellectual disability and alcohol use disorder

Virtual agents for peer pressure simulations remain underexplored in the latest literature. Yet, persuasive appeals by humans are vastly responsible for the development and upkeep of harmful behaviors (e.g. substance abuse, risky sexual behavior). In case the behavior becomes a habit, for instance in alcohol use disorders, therapy may be needed to guide affected patients toward behavior change. Here, training with virtual agents within Immersive Virtual Reality (IVR) could add to the current treatment practice, given that clinics lack actors and valid environments to train refusal skills realistically. In my PhD project, we designed and evaluated a persuasive IVR agent together with experts for alcohol use disorder treatments in people with a mild to borderline intellectual disability (IQ=50-85), given that this group was found at risk for the development and upkeep of addictive disorders. In future works, we aim to validate our IVR prototype with patients, by using a hostile or friendly interpersonal stance via natural persuasive speech features. Furthermore, multi-agent interactions appear interesting to improve the agent’s power within the group, for instance through ‘two against one’ dynamics

Go up in smoke:proof of concept study on tobacco craving in a VR environment

Background: Recent technological developments in virtual reality (VR) provide a potential to reduce the burden of tobacco addiction. Despite efforts to reduce smoking initiation and to increase smoking cessation, still approximately 19.2% of female and 25.7% of male adults in the Netherlands smoke. Recent research indicates even higher prevalence rates in vulnerable groups, such as individuals with intellectual disability, mental illness, or low socio-economic status. One of the factors in the persistence of tobacco related disorders, is that smoking cessation programs are only successful in about 10-16% of patients. Moreover, existing treatments may not be suitable for vulnerable groups, which might hinder uptake and effectiveness. Several studies in the area of VR have assessed the potential to evoke craving as part of cue-reactivity. However, research on cue-exposure therapy, which is based on the extinction of a conditioned response, reports only limited effects. Thus, teaching coping strategies in VR that are related to real-life situations, might be a potential approach for behavior change, especially in groups that barely benefit of existing cessation programs.Methods: This research comprises two evaluations with each three iterations as part of a user-centered development approach. Recruited participants were heavy smokers (Fagerström >= 5) from three Dutch healthcare institutions, involving individuals with intellectual disability, mental illness, and pulmonal issues. The first part of participants derived from every subgroup participated (1) to improve the cue-reactivity environment, procedure and related measurements. The other part applied (2) virtual coping strategies after being exposed to the previously improved cue-reactivity environment to explore and refine possibilities for craving reduction. Self-reported data (VAS, QSU-Brief), psychophysiological measures (GSR, HR), and eye-tracking were used as a potential continuous measurement of craving. Moreover, the think-aloud protocol was employed to improve the user’s experience based on the cognitive insights.Findings: Twenty-three participants participated in the first study group to improve the cue-reactivity and related measurements within the virtual environment. Preliminary results indicate a significantly increased level of craving after exposure compared to baseline. Participants in all subgroups successfully managed to use the VR-application while an increasing age revealed more problems in handling controls. Smoking-related cues and contexts were rated highly individually due to personal habits. The incorporated multimodal interactions involving smell, sound, and haptics have been identified to be important factors that influence cravings. Moreover, social influences and emotional distress have been reported to influence the urge to smoke. To continuously monitor craving levels in vulnerable groups, eye-tracking has been reported unfeasible due to complicate calibration procedures. Furthermore, motion artifacts and uncontrollable contextual variables might bias the measurement of galvanic skin responses.Discussion: The preliminary results are in line with the previous research in the field of VR cue-reactivity by showing significant increases in craving within the subgroup of vulnerable individuals. The iterative development approach indicates a need for highly personalizable environments with complex multimodal cues, that involve social interactions and affective influences. Future research should investigate the potential of coping skills training by providing scientifically validated relaxation and distraction exercises.Acknowledgement: This work is supported by the Pioneers in Health Care project GoUpInSmoke. The authors gratefully acknowledge the contribution of Sytze Sicco Smit, Christa ten Bolscher, Saskia van Horsen, and all our participants

Immersive Virtual Reality Avatars for Embodiment Illusions in People With Mild to Borderline Intellectual Disability: User-Centered Development and Feasibility Study

Background: Immersive Virtual Reality (IVR) has been investigated as tool for treating psychiatric conditions. Especially the practical nature of IVR, by offering a doing instead of talking approach, could support people who do not benefit from existing treatments. Hence, people with mild to borderline intellectual disability (MBID, IQ = 50-85) might profit particularly from IVR therapies, for instance, to circumvent issues in understanding relevant concepts and interrelations. In this context, immersing the user into a virtual body (i.e. avatar) appears promising for enhancing learning (e.g. by changing perspectives) and usability (e.g. natural interactions). However, design requirements, immersion procedures, and the proof of concept of such embodiment illusion (i.e. substituting the real body with a virtual one) have not been explored in this group. Objective: Our work aimed to establish design guidelines for IVR embodiment illusions in people with MBID. We explored three factors to induce the illusion, by testing the (1) avatar’s appearance, (2) locomotion using IVR controllers, and (3) virtual object manipulation. Further, we report on the feasibility to induce the embodiment illusion and provide procedural guidance. Methods: We conducted a user-centered design with 29 end-users in care facilities, to investigate the (1) avatar’s appearance, (2) controller-based locomotion (i.e. teleport, joystick, or hybrid), and (3) object manipulation. Three iterations were conducted using semi-structured interviews to explore design factors to induce embodiment illusions in our group. To further understand the influence of interactions on the illusion, we measured the Sense of Embodiment (SoE) during five interaction tasks. Results: IVR embodiment illusions can be induced in adults with MBID. To induce the illusion, having a high degree of control over the body outweighed avatar customization, despite the participants' desire to replicate the own body image. Likewise, the highest SoE was measured during object manipulation tasks, which required a combination of (virtual) locomotion and object manipulation behavior. Notable, interactions that are implausible (e.g. teleport, occlusions when grabbing) showed a negative influence on the SoE. Contrarily, implementing artificial interaction aids into the IVR avatar’s hands (i.e. for user interfaces) did not diminish the illusion, presuming that the control was unimpaired. Nonetheless, embodiment illusions showed a tedious and complex need for (control) habituation (e.g. motion sickness), possibly hindering uptake in practice. Conclusions: Balancing the embodiment immersion, by focusing on interaction habituation (e.g. controller-based locomotion) and lowering customization effort seems crucial to achieve both a high SoE and usability for people with MBID. Hence, future work should investigate requirements for natural IVR avatar interactions by using multisensory integrations for the virtual body (e.g. animations, physics-based collision, touch), and other interaction techniques (e.g. hand tracking, redirected walking). In addition, procedures and usage for learning should be explored for tailored mental health therapies in people with MBID

Suchthilfe bei Menschen mit einer Intelligenzminderung – mehr als ein angepasstes Programm

Das Fundament der Suchthilfe für Menschen mit Intelligenzminderung oder Lernbehinderung ist ein Versorgungsnetzwerk von Behinderten- und Suchthilfe mit konstruktiver Zusammenarbeit in den Bereichen Prävention, Screening, Frühintervention, kognitive Verhaltenstherapie und Rehabilitation/Begleitung. Die in den Niederlanden entwickelten Methoden wurden auch in Dänemark, Deutschland, Belgien und der frankofonen Schweiz implementiert. Indes entwickeln sich die Therapien in den Niederlanden weiter mit Fokus auf eine fortlaufende Begleitung in der Behindertenhilfe, der Behandlung von spezifischen Komorbiditäten sowie den Einsatz von digitalen Technologien

Development of an alcohol refusal training in Immersive Virtual Reality for patients with Mild to Borderline Intellectual Disability and Alcohol Use Disorder: Co-creation with experts in addiction care

BackgroundPeople with mild to borderline intellectual disability (MBID; IQ=50-85) are at risk for developing an alcohol use disorder (AUD). One factor contributing to this risk is sensitivity to peer pressure. Hence, tailored trainings are needed to practice alcohol refusal in impacted patients. Immersive virtual reality (IVR) appears promising to engage patients in dialogs with virtual humans, allowing to practice alcohol refusal realistically. However, requirements for such an IVR have not been studied for MBID/AUD. ObjectiveThis study aims to develop an IVR alcohol refusal training for patients with MBID and AUD. In this work, we cocreated our peer pressure simulation with experienced experts in addiction care. MethodsWe followed the Persuasive System Design (PSD) model to develop our IVR alcohol refusal training. With 5 experts from a Dutch addiction clinic for patients with MBID, we held 3 focus groups to design the virtual environment, persuasive virtual human(s), and persuasive dialog. Subsequently, we developed our initial IVR prototype and conducted another focus group to evaluate IVR and procedures for clinical usage, resulting in our final peer pressure simulation. ResultsOur experts described visiting a friend at home with multiple friends as the most relevant peer pressure situation in the clinical setting. Based on the identified requirements, we developed a social-housing apartment with multiple virtual friends present. Moreover, we embedded a virtual man with generic appearance to exert peer pressure using a persuasive dialog. Patients can respond to persuasive attempts by selecting (refusal) responses with varying degrees of risk for relapse in alcohol use. Our evaluation showed that experts value a realistic and interactable IVR. However, experts identified lacking persuasive design elements, such as paralanguage, for our virtual human. For clinical usage, a user-centered customization is needed to prevent adverse effects. Further, interventions should be therapist delivered to avoid try-and-error in patients with MBID. Lastly, we identified factors for immersion, as well as facilitators and barriers for IVR accessibility. ConclusionsOur work establishes an initial PSD for IVR for alcohol refusal trainings in patients with MBID and AUD. With this, scholars can create comparable simulations by performing an analogous cocreation, replicate findings, and identify active PSD elements. For peer pressure, conveying emotional information in a virtual human’s voice (eg, paralanguage) seems vital. However, previous rapport building may be needed to ensure that virtual humans are perceived as cognitively capable entities. Future work should validate our PSD with patients and start developing IVR treatment protocols using interdisciplinary teams