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9 Coping with Stress and Anxiety: the Role of Presence in Technology Mediated Environments 9 Coping with Stress and Anxiety: the Role of Presence in Technology Mediated Environments Daniela Villani, Pietro Cipresso, and Claudia Repetto Abstract: Several studies in the last decades have demonstrated that exposure therapy is an effective way to treat anxiety and stress and Virtual Reality Exposure Therapy (VRET) acts as a completely controlled experience. A new perspective is represented by the use of Virtual Reality (VR) for triggering a broad empowerment process to learn coping skills and emotional regulation to cope with stress and anxiety. The link between these approaches is constituted by the sense of presence. In this view, the experience of “being there” is influenced by the ability of “making sense there” and by the possibility to learn by living real experiences in technology-mediated environments. Thanks to the integration of several advanced technologies (virtual reality, advanced sensors and smartphones), as supported by the Interreality approach, it is possible to take advantage of the sense of presence to overcome the limitations of existing protocols for psychological stress and anxiety. Furthermore, a larger availability of unobtrusive biosensors makes possible the effective measurement of presence (and the related affective states) during the interaction instead of using post-experience self-assessments. Future mediated platforms will provide the following advantages: 1) increased accuracy in assessment of ongoing intervention processes; 2) the ability to correlate specific mental states with specific activities executed in the environments; 3) the ability to study the variables related to stress and anxiety in the framework of simulations representing realistic situations and daily contexts, thus increasing the ecological validity of gathered data. Keywords: Stress; Anxiety; Presence; New Technologies; Mobile Devices; Interreality. 9.1 Introduction to Chapter 9 To answer to the growing need to find innovative and effective interventions in healthcare services to cope with stress and anxiety, an increasing number of studies show how interactive media may improve traditional stress management interventions (Gorini & Riva, 2008a, 2008b; Powers & Emmelkamp, 2008; Preziosa A., 2009; Repetto et al., 2013; Villani & Riva, 2012; Gaggioli & Riva, 2014). Three different approaches of interactive media used to cope with stress and anxiety emerge from literature. The Virtual Reality Exposure Therapy (VRET) represents the traditional one. Following this approach, the users, immersed within a computer-generated simulation or virtual environment (VE), can be systematically exposed to specific feared stimuli © 2014 Daniela Villani, Pietro Cipresso, Claudia Repetto This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License. 140 Coping with Stress and Anxiety: the Role of Presence in Technology Mediated Environments within a contextually relevant setting. The rationale for this view typically derives from early evidence that VRET produces better outcomes than imaginal exposure, provides equivalent outcomes and is a pragmatically attractive alternative to in vivo exposure, such as the real-world confrontation of feared stimuli (Emmelkamp et al., 2002). According to Parsons and colleagues (Parsons & Rizzo, 2008) empirical data from research positively assessed the efficacy of VRET on affective outcomes and consensus exists about the good potential of VRET as a treatment approach for several anxiety disorders (Botella et al., 2004; Goncalves, Pedrozo, Coutinho, Figueira, & Ventura, 2012; Krijn, Emmelkamp, Olafsson, & Biemond, 2004; Meyerbroker & Emmelkamp, 2010; Pull, 2005). The second new and applied approach, the Positive Technology (PT), aims to improve the quality of the personal experience with the goal of increasing wellness and generating strengths and resilience. (Botella et al., 2012; Riva, Banos, Botella, Wiederhold, & Gaggioli, 2012). Within this perspective, in the last 10 years several studies have shown the possibility of interactive media to support empowerment processes in terms of relaxation training and improvement in self-efficacy and emotional management (Plante et al., 2003; Plante, Cage, Clements, & Stover, 2006; Valtchanov, 2010; Villani et al., 2013; Villani, Riva, & Riva, 2007; Villani & Riva, 2012). Findings indicate that a sense of flourishing and resilience can be promoted by interventions leading to a positive evaluation of one’s self and to the capacity to manage one’s life effectively. Furthermore, according to Fredrickson (2001; 2009), positive emotions can play a critical role for mental and physical health because, even though a positive emotional state is only momentary, benefits can last in the form of traits, social bonds, and abilities that endure well into the future and that can help people to cope with several stressors. A third approach is represented by the use of Cyber-interventions based on the Stress Inoculation Training protocol (Cyber-SIT). The general objectives of SIT (Meichenbaum, 1977; 1996) are threefold: to acquire active coping strategies; to develop an activity of self-regulation; to explore and modify dysfunctional cognitive appraisal related to stressful events. According to the systematic review recently presented by Serino and colleagues (Serino et al., 2013), Cyber-SIT appears a promising clinical approach, and there are interesting researches that effectively combined traditional SIT clinical protocol within advanced technologies. (Grassi, Gaggioli, & Riva, 2011; Villani et al., 2013). Specifically, Cyber-SIT combines aspects deriving both from the traditional perspective of VRET and from the innovative perspective of Positive Technology. These aspects are evident in two phases of SIT. As far as the skill acquisition and rehearsal phase is concerned, advanced technologies can help individuals in acquiring effective coping skills, such as relaxation strategies (Manzoni et al., 2009; Stetz et al., 2011; Villani, Grassi, et al., 2012) by doing exercises, with technology administering positive reinforcement of healthy conduct (Fox & Bailenson, 2009). As far as the application and follow-through phase is concerned, it is possible to create controlled, graded and safe simulations of stressful scenarios to Presence as a Link Among Different Approaches 141 allow participant to use the acquired coping skills based on the exposure approach. Nevertheless, there are still few studies in the literature meeting the requirement of using cyber-SIT in all its clinical elements and phases. Work has to be done to achieve rigor and generalizability from a methodological point of view. What is the key factor that links together these approaches apparently so different from each other? We consider that a key role in supporting the change process allowed by all these approaches is played by the sense of presence. 9.2 Presence as a Link Among Different Approaches Although the concept of presence has been investigated from various perspectives that have accordingly proposed different definitions, we would like to overcome these conflicting standpoints by emphasizing that the experience of “being there” is influenced by the ability of “making sense there” and by the possibility of learning by living real experiences in virtual environments (see also Chapters 1 and 2, this volume). To achieve the ability of “making sense there” is important to take in consideration several aspects of action. First, it is important to work not only on the environmental features but also on the proposed content inside the mediated experience (Grassi, Gaggioli, & Riva, 2009; Riva et al., 2007; Villani, & Riva, 2009). In accordance with Scherer et al.’s (Scherer, Schorr, & Johnstone, 2001) theory we consider the coherence between the content and the goal of the multimedia experience to be critical. We suggest that it is important to critically choose the sampling strategies according to the specific aim of the protocol. Participants may feel more engaged if they consider the experience to be crucial for their needs and goals, and this is also true for mediated experiences (Riva & Mantovani, 2012). A second perspective suggests that it is possible to work on the content a priori, but the assignment of meaning is a subjective process emerging during the experience. This issue has been showed in experimental research carried out by Villani and colleagues (Villani, Repetto, Cipresso, & Riva, 2012). Authors compared the experienced feeling of presence in two different settings: an immersive virtual reality job interview simulation and a real world simulation that was identical to its VR counterpart (same interviewer, same questions) but without technological mediation and without any social and cultural cues in the environment that could give a better meaning to both the task and its social context. Results suggested that a virtual experience could elicit a higher sense of presence if the meaning and the emotional engagement are higher than in real experience. This result supports a conception of presence as a social construction (Mantovani, 1996; Riva, 1999) that is different from the ‘‘perceptual illusion of non-mediation’’ suggested by Lombard and Ditton (Lombard & Ditton, 1997).. In this sense, ‘‘reality’’ is not out there in the world, somewhere ‘‘outside’’ people’s minds, escaping social negotiation and 142 Coping with Stress and Anxiety: the Role of Presence in Technology Mediated Environments cultural mediation; reality is co-constructed in the relationship
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