CYBERTHERAPY CONFERENCE 2008
Environment: Preliminary Study of Cover
Jiyoon Moon, B.A., Jang-Han Lee, Ph.D.
Department of Psychology, Chung-Ang University
Clinical Neuro-pSychology Lab. Department of Psychology, Chung-Ang University
Introduction
Subjective cue-elicited
reactions
Cue Reactivity
A classical conditioned response
pattern that occurs when an
addicted subject is exposed to
drug-related stimuli
 Craving
 Withdrawal symptoms
 Drug-agonistic effect
 Mood swings
Physiological reactions
 Skin conductance
 Heart Rate
 Salivation
 Body temperature
Brain activity
Introduction
 Aversion Therapy
(grounded in classical conditioning)
repeatedly
paired
Taste aversion learning (Garcia, 1955)
UCS
CS
UCR
UCS
UCR
Introduction
 Covert Sensitization (Cautela, 1966)
- Imagery based behavior aversion therapy
- Verbal aversion procedure which presents aversive stimuli (e.g.
nausea, physical deterioration or embarrassment) through
imagery
- Covert aversive conditioning procedure
: sensitizing a client to inappropriate pleasurable stimuli
: Undesirable behavior + unpleasant image
→ Directly eliminating the behavior
UCS +
UCS
UCR
Introduction
An Example Description
I want you to imagine you’ve just had your main meal and you are about
to eat your dessert, which is apple pie. As you are about to reach for the
fork, you get a funny feeling in the pit of your stomach. You start to feel
queasy, nauseous, and sick all over. As you touch the fork, you can feel food
particles inching up in your throat. You’re just about to vomit. As you put
the fork into the pie, the food comes up into your mouth. You try to keep
your mouth closed because you are afraid that you’ll spit the food out all
over the place. You bring the piece of pie to your mouth. As you are about
to open your mouth, you puke; you vomit all over your hands, the fork,
over the pie. It goes all over the table, over other people’s food. Your eyes
are watering. Snots, mucus are all over your mouth and nose. Your hands
feel sticky. There is an awful smell. As you look at the mess you just can’t
help but vomit again and again until just watery stuff is coming out.
Everybody is looking at you with a shocked expression. You turn away
from the food and immediately start to feel better. You run out of the room
and, as you run out, you feel Better and better. You wash and clean
yourself up and it feels wonderful. (Cautela, 1972, p. 10)
Introduction
 Advantage
- Relatively risk-free compared with other aversive
treatments
- Known to be an effective treatment
- Can be used to treat almost any maladaptive approach
behavior
(best results: addiction, Obesity, and sexual disorders)
would be solved with VR
- Highly relying on individual’s ability of imagination
- Controlling covert stimuli
Disadvantage
 Advantages of virtual reality in covert sensitization
- Helping increase one’s imagination
- Setting up standardized situation
Method
 Preliminary survey to develop virtual
environments and scenarios
- Survey participants
Ward group
Normal group
14 Alcohol dependence
inpatients (DSM-IV)
51 Light drinkers
(All university students)
23.10 (SD=1.92) years
39.10 (SD=10.60) years
Method
 The open-ended questions
Questions
How unpleasant is the
situation / person?
1) List fearful situations which are likely to
happen due to excessive drinking
①--②--③--④--⑤--⑥--⑦--⑧--⑨--⑩
2) List three regretful situations which are
likely to happen due to excessive drinking
①--②--③--④--⑤--⑥--⑦--⑧--⑨--⑩
3) List three persons who the most make
you feel guilty after alcohol use
①--②--③--④--⑤--⑥--⑦--⑧--⑨--⑩
Health risks
Suffering from a hangover
Family members
→ From the results of this survey, VR-covert sensitization
scenarios were created
Method
Virtual Hospital
Method
Virtual Subway
Method_Experiment 1
Validity test of two virtual environments
 Participants
- 17 university students (9 male & 8 female)
- Mean age: 20.24 (SD = 1.92) years
- Average drinking amount of beer : 1230 (SD = 366) cc
 Measurement of Craving (VAS)
 VR instrument
- Pentium IV PC, Open GL Accelerator VGA card, a beam
projector screen (2.4m * 1.8m), surround speaker
Method & Result_Experiment 1
 Procedure
S1
S2
S3
S4
S5
current
craving
CS in
Virtual hospital
current
craving
CS in
virtual subway
current
Craving
A couple of days ago, I had a
medical examination. I get tired
easily for no apparent reason.
It’s 6 in the afternoon. I feel
hungry. I will have dinner, of
course with some alcohol, as soon
as finishing hospital thing.
…
“Can you see this white circle on
your x-ray result? You have
hepatic failure. You have to stop
drinking
…
I drank alcohol with friends. It’s time
to go home. I’ll take the subway. Oooh,
I feel dizzy and uncomfortable.
…
I get on the subway. Ooh, I feel
uncomfortable.
…
I puked. you vomit all over your
hands, subway, and the person next
you. People are blaming. I cannot
stand this shame. I’ll get off when the
subway stops. But subway never
stops. I cannot feel more
embarrassing.
Result_Experiment 1
How much do you want to drink?
 Self-report of craving through the sessions
- Significant reduction in craving (F=16.252, p<.001)
- Significant reduction in cue craving (F=38.018, p<.001)
*Virtual environments for covert sensitization
: aversive enough to decrease craving
Method_Experiment 2
Soju
Virtual CS for alcohol dependent patients
 Participant
- 2 alcohol dependent inpatients
Type of alcohol in Korea
360ml
 cheap, moderate-proof (21%),
and popular
Name
Y
P
Age
40
42
Days of alcohol
drinking / month
30 days
3 days
Drinking amount
5 bottles of soju
5 bottles of soju
History of
2 times / 77 days
- hospitalization
drank 5 bottles of soju daily
7 times / 350
days
 Measurement
- Self-report of craving (VAS)
- Alcohol-Implicit Association Test (IAT)
Method_Experiment 2
Alcohol-IAT
Implicit Association Test (Greenwald, McGhee, & Schwartz, 1998)
- Well-validated measurement for implicit attitudes
- Alcohol consumption ← Stigmatized behavior
Alcohol dependence :
negative self-reported
attitudes to alcohol
consumption
Cognitively accommodating
the stigmatized behavior
at the explicit,
but not implicit, level
<Operation of the IAT>
d
k
positive negative
good
Soft drink
Alcohol
Tequila
Positive
negative
Soft drink Alcohol
bad
Alcohol
Soft drink
Coke
Positive Negative
Alcohol Soft drink
Tequila
Method_Experiment 2
Outline of the Research
Questionnaire
Alcohol-IAT
VR-Covert Sensitization
Alcohol-IAT
Questionnaire
• demographic data, AUQ, History of (problematic)
alcohol drinking, craving, etc.
To see changes in attitudes to alcohol
Free
Navigation of
“Virtual City”
Covert
sensitization in
“Virtual Subway”
• about 60 min, including
Introduction
Covert sensitization,
Interviews about feelings
Self-report questionnaire of craving
Result_Experiment 2
 Self-report data: Decreased AUQ, Craving, and Cue Craving
How much do you want to drink?
Result_Experiment 2
 Implicit Attitude – not consistent
Y
P
 Interviews
Y
P
I don’t usually puke after drinking.
I’ve never puked on the subway…
but I’ve puked at home many times.
This reminds me of the experience.
It’s painful.
If someone is totally drunken, one
cannot remember anything.
‘Getting on the subway’ means that
one is not severely drunken.
But this kind of situation is really
embarrassing.
Discussion
 The merits of this study
- More controlled therapy compared to traditional verbal covert
sensitization
- Making up for one’s poor imagination
- Covert sensitization in VE seems to be effective to reduce
alcohol craving by offering vivid experience
 Limitations
-
Not individualized virtual environments & scenarios
Small sample size: need to extend samples
Short sessions
Absence of follow-up investigation