The need for psychotherapy is very high and the lack of care causes a lot of suffering and high costs. This paper presents an interdisciplinary approach to creating an AI-guided exposure therapy for fear of heights in virtual reality (VR). First, ethical principles for the use of conversational AI in psychotherapy were translated into technical requirements and made measurable. Based on this, an autonomous virtual reality exposure therapy was iteratively developed with a therapist. The feasibility and implementation of the ethical principles were tested with a patient. The patient was very satisfied with the VR setup. The AI therapist was also rated positively, although there is still room for improvement regarding conversational skills. Overall, the paper shows how AI can contribute responsibly to improving the psycho-therapeutic supply. It also provides guidelines that make ethical principles tangible and measurable for developers.
References
[1]
Domschke, K. (2021) Update Angsterkrankungen-Aktueller Stand und neue Entwicklungen. DerNervenarzt, 92, 415-416. https://doi.org/10.1007/s00115-020-01042-4
[2]
Altenhofer, M., et al. (2021) Virtual-Reality-Therapie: Anwendung in Klinischer Psychologie und Psychotherapie. Springer, Berlin. https://doi.org/10.1007/978-3-662-63457-8
[3]
(2024) Psychisch Kranke warten 142 Tage auf eine Psychotherapie. https://bptk.de/psychisch-kranke-warten-142-tage-auf-eine-psychotherapeutische-behandlung
[4]
Plötner, M., Moldt, K., In-Albon, T. and Schmitz, J. (2022) Einfluss der COVID-19-Pandemie auf die ambulante psychotherapeutische Versorgung von Kindern und Jugendlichen. Die Psychotherapie, 67, 469-477. https://doi.org/10.1007/s00278-022-00604-y
[5]
Bundestag, D. (2022) Wartezeiten auf eine Psychotherapie Studien und Umfragen. https://www.bundestag.de/resource/blob/916578/53724d526490deea69f736b1fda83e76/WD-9-059-22-pdf-data.pdf
[6]
Parsons, T.D. and Rizzo, A.A. (2008) Affective Outcomes of Virtual Reality Exposure Therapy for Anxiety and Specific Phobias: A Meta-Analysis. Journal of Behavior Therapy and Experimental Psychiatry, 39, 250-261. https://www.sciencedirect.com/science/article/pii/S0005791607000456 https://doi.org/10.1016/j.jbtep.2007.07.007
[7]
Emmelkamp, P.M.G., et al. (2002) Virtual Reality Treatment versus Exposure in Vivo: A Comparative Evaluation in Acrophobia. Behaviour Research and Therapy, 40, 509-516. https://doi.org/10.1016/S0005-7967(01)00023-7
[8]
Kuhn, E., Fiske, A., Henningsen, P. and Buyx, A. (2021) Psychotherapie mit einer autonomen Künstlichen Intelligenz-Ethische Chancen und Herausforderungen 1. Psychiatrische Praxis, 48, S26-S30. http://www.thieme-connect.de/DOI/DOI?10.1055/a-1369-2938 https://doi.org/10.1055/a-1369-2938
DAK (2023) Sick Days Due Taken to Mental Illness in Germany from 1997 to 2022. https://www.statista.com/statistics/1372953/sick-leave-index-mental-illness-germany/
Statista Research Department (2011) Häufigkeit von Angststörungen in der gesamtbevölkerung. https://de.statista.com/statistik/daten/studie/182616/umfrage/haeufigkeit-von-angststoerungen/
[13]
Statista Research Department (2024) Topic: Anxiety in the U.S. https://www.statista.com/topics/5223/anxiety-in-the-us/#topicOverview
[14]
Wittchen, H.U. (1997) Wenn Angst krank macht. Störungen erkennen, verstehen und behandeln. https://api.semanticscholar.org/CorpusID:142233292
[15]
Reynolds, S., Wilson, C., Austin, J. and Hooper, L. (2012) Effects of Psychotherapy for Anxiety in Children and Adolescents: A Meta-Analytic Review. Clinical Psychology Review, 32, 251-262. https://www.sciencedirect.com/science/article/pii/S0272735812000219 https://doi.org/10.1016/j.cpr.2012.01.005
[16]
Foa, E.B. and Kozak, M.J. (1986) Emotional Processing of Fear: Exposure to Corrective Information. Psychological Bulletin, 99, 20-35. https://doi.org/10.1037//0033-2909.99.1.20
[17]
Steinman, S.A., Wootton, B.M. and Tolin, D.F. (2016) Exposure Therapy for Anxiety Disorders. In: Friedman, H.S., Ed., Encyclopedia of Mental Health (Second Edition), Academic Press, Oxford, 186-191. https://www.sciencedirect.com/science/article/pii/B9780123970459002664 https://doi.org/10.1016/B978-0-12-397045-9.00266-4
[18]
Rabe-Menssen, C., Ruh, M. and Dazer, A. (2019) Die Versorgungssituation seit der Reform der Psychotherapie-Richtlinie 2017. PsychotherAktuell, 1, 25-34.
[19]
Eichenberg, C. and Wolters, C. (2012) Virtual Realities in the Treatment of Mental Disorders: A Review of the Current State of Research. In: Eichenberg, C., Ed., Virtual Reality in Psychological, Medical and Pedagogical Applications, IntechOpen, London, 35-64. https://doi.org/10.5772/50094
[20]
Wienrich, C., Döllinger, N. and Hein, R. (2021) Behavioral Framework of Immersive Technologies (BehaveFIT): How and Why Virtual Reality Can Support Behavioral Change Processes. Frontiers in Virtual Reality, 2, Article 627194. https://doi.org/10.3389/frvir.2021.627194
[21]
Krijn, M., Emmelkamp, P.M.G., Olafsson, R.P. and Biemond, R. (2004) Virtual Reality Exposure Therapy of Anxiety Disorders: A Review. Clinical Psychology Review, 24, 259-281. https://doi.org/10.1016/j.cpr.2004.04.001
[22]
Powers, M.B. and Emmelkamp, P.M.G. (2008) Virtual Reality Exposure Therapy for Anxiety Disorders: A Meta-Analysis. Journal of Anxiety Disorders, 22, 561-569. https://doi.org/10.1016/j.janxdis.2007.04.006
[23]
Morina, N., et al. (2015) Can Virtual Reality Exposure Therapy Gains Be Generalized to Real-Life? A Meta-Analysis of Studies Applying Behavioral Assessments. Behaviour Research and Therapy, 74, 18-24. https://www.sciencedirect.com/science/article/pii/S0005796715300334 https://doi.org/10.1016/j.brat.2015.08.010
[24]
García-Palacios, A., et al. (2001) Redefining Therapeutic Success with Virtual Reality Exposure Therapy. Cyberpsychology & Behavior, 4, 341-348. https://api.semanticscholar.org/CorpusID:18061881 https://doi.org/10.1089/109493101300210231
[25]
Powers, M. and Emmelkamp, P. (2008) Virtual Reality Exposure Therapy for Anxiety Disorders: A Meta-Analysis. Journal of Anxiety Disorders, 22, 561-569. https://doi.org/10.1016/j.janxdis.2007.04.006
[26]
Rothbaum, B.O., et al. (2000) A Controlled Study of Virtual Reality Exposure Therapy for the Fear of Flying. Journal of consulting and Clinical Psychology, 68, 1020-1026. https://doi.org/10.1037/0022-006X.68.6.1020
[27]
Rimer, E., Husby, L.V. and Solem, S. (2021) Virtual Reality Exposure Therapy for Fear of Heights: Clinicians’ Attitudes Become More Positive after Trying VRET. Frontiers in Psychology, 12, Article 671871. https://doi.org/10.3389/fpsyg.2021.671871
[28]
Reger, G.M., et al. (2011) Effectiveness of Virtual Reality Exposure Therapy for Active Duty Soldiers in a Military Mental Health Clinic. Journal of Traumatic Stress, 24, 93-96. https://onlinelibrary.wiley.com/doi/pdf/10.1002/jts.20574 https://doi.org/10.1002/jts.20574
[29]
Meyer-Lindenberg, A. (2018) Artificial Intelligence in Psychiatry—An Overview. DerNervenarzt, 89, 861-868. https://doi.org/10.1007/s00115-018-0557-6
[30]
Sedlakova, J. and Trachsel, M. (2023) Conversational Artificial Intelligence in Psychotherapy: A New Therapeutic Tool or Agent? The American Journal of Bioethics, 23, 4-13. https://doi.org/10.1080/15265161.2022.2048739
[31]
Eke, D.O. (2023) ChatGPT and the Rise of Generative AI: Threat to Academic Integrity? Journal of Responsible Technology, 13, Article ID: 100060. https://doi.org/10.1016/j.jrt.2023.100060
[32]
Miner, A.S., et al. (2019) Key Considerations for Incorporating Conversational AI in Psychotherapy. Frontiers in Psychiatry, 10, Article 746. https://doi.org/10.3389/fpsyt.2019.00746
[33]
Fiske, A., Henningsen, P. and Buyx, A. (2019) Your Robot Therapist Will See You Now: Ethical Implications of Embodied Artificial Intelligence in Psychiatry, Psychology, and Psychotherapy. Journal of Medical Internet Research, 21, e13216. https://doi.org/10.2196/13216
[34]
Meadows, R., Hine, C. and Suddaby, E. (2020) Conversational Agents and the Making of Mental Health Recovery. Digital Health, 6, 1-11. https://doi.org/10.1177/2055207620966170
[35]
Fitzpatrick, K.K., Darcy, A. and Vierhile, M. (2017) Delivering Cognitive Behavior Therapy to Young Adults with Symptoms of Depression and Anxiety Using a Fully Automated Conversational Agent (Woebot): A Randomized Controlled Trial. JMIR Mental Health, 4, e7785. https://doi.org/10.2196/mental.7785
[36]
Malik, T., Ambrose, A.J. and Sinha, C. (2022) Evaluating User Feedback for an Artificial Intelligence-Enabled, Cognitive Behavioral Therapy-Based Mental Health App (Wysa): Qualitative Thematic Analysis. JMIR Human Factors, 9, e35668. https://doi.org/10.2196/35668
[37]
Beatty, C., et al. (2022) Evaluating the Therapeutic Alliance with a Free-Text CBT Conversational Agent (Wysa): A Mixed-Methods Study. Frontiers in Digital Health, 4, Article 847991. https://doi.org/10.3389/fdgth.2022.847991
[38]
Freeman, D., et al. (2018) Automated Psychological Therapy Using Immersive Virtual Reality for Treatment of Fear of Heights: A Single-Blind, Parallel-Group, Randomised Controlled Trial. The Lancet Psychiatry, 5, 625-632. https://doi.org/10.1016/S2215-0366(18)30226-8
[39]
Martin, D.J., Garske, J.P. and Davis, M.K. (2000) Relation of the Therapeutic Alliance with Outcome and Other Variables: A Meta-Analytic Review. Journal of Consulting and Clinical Psychology, 68, 438-450. https://doi.org/10.1037//0022-006X.68.3.438
[40]
Ethikrat, D. (2023) Mensch und Maschine-Herausforderungen durch Künstliche Intelligenz. Stellungnahme,Berlin.
[41]
Rubeis, G. and Steger, F. (2019) Internet-und mobilgestützte Interventionen bei psychischen Störungen: Implementierung in Deutschland aus ethischer Sicht. DerNervenarzt, 90, 497-502. https://doi.org/10.1007/s00115-018-0663-5
[42]
Croes, E.A.J. and Antheunis, M.L. (2021) 36 Questions to Loving a Chatbot: Are People Willing to Self-Disclose to a Chatbot? In: Følstad, A., et al., Eds., CONVERSATIONS 2020:Chatbot Research and Design,Springer, Cham, 81-95. https://doi.org/10.1007/978-3-030-68288-0_6
[43]
Lucas, G.M., Gratch, J., King, A. and Morency, L.P. (2014) It’s Only a Computer: Virtual Humans Increase Willingness to Disclose. Computers in Human Behavior, 37, 94-100. https://doi.org/10.1016/j.chb.2014.04.043
[44]
Holthöwer, J. and van Doorn, J. (2023) Robots Do Not Judge: Service Robots Can Alleviate Embarrassment in Service Encounters. Journal of the Academy of Marketing Science, 51, 767-784. https://doi.org/10.1007/s11747-022-00862-x
[45]
Bartneck, C., et al. (2010) The Influence of Robot Anthropomorphism on the Feelings of Embarrassment When Interacting with Robots. Paladyn, 1, 109-115. https://doi.org/10.2478/s13230-010-0011-3
[46]
Beauchamp, T.L. and Childress, J.F. (2001) Principles of Biomedical Ethics. Oxford University Press, Oxford.
[47]
Flückiger, C., et al. (2018) The Alliance in Adult Psychotherapy: A Meta-Analytic Synthesis. Psychotherapy, 55, 316-340. https://doi.org/10.1037/pst0000172
[48]
Bickmore, T., Gruber, A. and Picard, R. (2005) Establishing the Computer-Patient Working Alliance in Automated Health Behavior Change Interventions. Patient Education and Counseling, 59, 21-30. https://doi.org/10.1016/j.pec.2004.09.008
[49]
Reeves, B. and Nass, C. (1996) The Media Equation: How People Treat Computers, Television, and New Media Like Real People. Center for the Study of Language and Inf, Cambridge.
[50]
Wienrich, C., Reitelbach, C. and Carolus, A. (2021) The Trustworthiness of Voice Assistants in the Context of Healthcare Investigating the Effect of Perceived Expertise on the Trustworthiness of Voice Assistants, Providers, Data Receivers, and Automatic Speech Recognition. Frontiers in Computer Science, 3, Article 685250. https://doi.org/10.3389/fcomp.2021.685250
[51]
Philip, P., et al. (2020) Trust and Acceptance of a Virtual Psychiatric Interview between Embodied Conversational Agents and Outpatients. NPJ Digital Medicine, 3, Article No. 2. https://doi.org/10.1038/s41746-019-0213-y
[52]
Lee, S.K., Kavya, P. and Lasser, S.C. (2021) Social Interactions and Relationships with an Intelligent Virtual Agent. International Journal of Human-Computer Studies, 150, Article ID: 102608. https://doi.org/10.1016/j.ijhcs.2021.102608
[53]
Lee, S.K., Park, H. and Kim, S.Y. (2024) Gender and Task Effects of Human-Machine Communication on Trusting a Korean Intelligent Virtual Assistant. Behaviour & Information Technology. https://doi.org/10.1080/0144929X.2024.2306136
[54]
Obremski, D., Hering, H.B., Friedrich, P. and Lugrin, B. (2022) Mixed-Cultural Speech for Intelligent Virtual Agents—The Impact of Different Non-Native Accents Using Natural or Synthetic Speech in the English Language. Proceedings of the 10th International Conference on Human-Agent Interaction, Christchurch, 5-8 December 2022, 67-75. https://doi.org/10.1145/3527188.3561921
[55]
Elkins, A.C. and Derrick, D.C. (2013) The Sound of Trust: Voice as a Measurement of Trust during Interactions with Embodied Conversational Agents. Group Decision and Negotiation, 22, 897-913. https://doi.org/10.1007/s10726-012-9339-x
[56]
Obremski, D., Friedrich, P., Schaper, P. and Lugrin, B. (2023) Effects of Social Ingroup Cues on Empathy towards an Intelligent Virtual Agent with a Mixed-Cultural Background. 11th International Conference on Affective Computing and Intelligent Interaction (ACII), Cambridge, 10-13 September 2023, 1-8. https://doi.org/10.1109/ACII59096.2023.10388206
[57]
Akbar, S., Coiera, E. and Magrabi, F. (2020) Safety Concerns with Consumer-Facing Mobile Health Applications and Their Consequences: A Scoping Review. Journal of the American Medical Informatics Association, 27, 330-340. https://doi.org/10.1093/jamia/ocz175
[58]
Samek, W., et al. (2021) Explaining Deep Neural Networks and beyond: A Review of Methods and Applications. Proceedings of the IEEE, 109, 247-278. https://doi.org/10.1109/JPROC.2021.3060483
[59]
Ethikrat, D. (2023) Stellungnahme der Deutschen Gesellschaft für Psychologie auf die Schrift des Deutschen Ethikrates zu Mensch und Maschine-Herausforderungen durch Künstliche Intelligenz KI-basierte Systeme als Ersatz für Psychotherapie? Ein eindeutiges Nein! Deutscher Ethikrat, Berlin. https://www.ethikrat.org/fileadmin/Publikationen/Stellungnahmen/deutsch/stellungnahme-mensch-und-maschine.pdf
[60]
Agić, A., Murseli, E., Mandić, L. and Skorin-Kapov, L. (2020) The Impact of Different Navigation Speeds on Cybersickness and Stress Level in VR. Journal of Graphic Engineering and Design, 11, 5-12. https://doi.org/10.24867/JGED-2020-1-005
[61]
Silka, H. and Gebauer, M. (2023) Therapie-Tools Angststörungen. Beltz, Frankfurt.
[62]
Wienrich, C. and Latoschik, M.E. (2021) Extended Artificial Intelligence: New Prospects of Human—AI Interaction Research. Frontiers in Virtual Reality, 2, Article 686783. https://doi.org/10.3389/frvir.2021.686783
[63]
Latoschik, M.E. and Wienrich, C. (2022) Congruence and Plausibility, Not Presence: Pivotal Conditions for XR Experiences and Effects, a Novel Approach. Frontiers in Virtual Reality, 3, Article 694433. https://doi.org/10.3389/frvir.2022.694433
[64]
Lazarus, R.S., Speisman, J.C. and Mordkoff, A.M. (1963) The Relationship between Autonomic Indicators of Psychological Stress: Heart Rate and Skin Conductance. Psychosomatic Medicine, 25, 19-30. https://doi.org/10.1097/00006842-196301000-00004
[65]
Zhang, Z.H. and Fort, J.M. (2023) Facial Expression Recognition in Virtual Reality Environments: Challenges and Opportunities. Frontiers in Psychology, 14, Article 1280136. https://doi.org/10.3389/fpsyg.2023.1280136
[66]
Zhao, Y.H. and Shu, X.Q. (2023) Speech Emotion Analysis Using Convolutional Neural Network (CNN) and γ Classifier-Based Error Correcting Output Codes (ECOC). Scientific Reports, 13, Article No. 20398. https://doi.org/10.1038/s41598-023-47118-4
[67]
McLennan, S., et al. (2022) Embedded Ethics: A Proposal for Integrating Ethics into the Development of Medical AI. BMC Medical Ethics, 23, Article No. 6. https://doi.org/10.1186/s12910-022-00746-3