Virtual-reality-based multidimensional therapy for the treatment of body image disturbances in binge eating disorders: a preliminary controlled study

224 IEEE TRANSACTIONS ON INFORMATION TECHNOLOGY IN BIOMEDICINE, VOL. 6, NO. 3, SEPTEMBER 2002

Virtual-Reality-Based Multidimensional Therapy forthe Treatment of Body Image Disturbances in BingeEating Disorders: A Preliminary Controlled Study

Giuseppe Riva, Monica Bacchetta, Margherita Baruffi, and Enrico Molinari

Abstract—The main goal of this paper is to preliminarily eval-uate the efficacy of a virtual-reality (VR)-based multidimensionalapproach in the treatment of body image attitudes and relatedconstructs. The female binge eating disorder (BED) patients( = 20), involved in a residential weight control treatment in-cluding low-calorie diet (1200 cal/day) and physical training, wererandomly assigned either to the multidimensional VR treatmentor to psychonutritional groups based on the cognitive-behaviorapproach. Patients were administered a battery of outcomemeasures assessing eating disorders symptomathology, attitudestoward food, body dissatisfaction, level of anxiety, motivation forchange, level of assertiveness, and general psychiatric symptoms.In the short term, the VR treatment was more effective thanthe traditional cognitive-behavioral psychonutritional groupsin improving the overall psychological state of the patients. Inparticular, the therapy was more effective in improving bodysatisfaction, self-efficacy, and motivation for change. No signifi-cant differences were found in the reduction of the binge eatingbehavior. The possibility of inducing a significant change in bodyimage and its associated behaviors using a VR-based short-termtherapy can be useful to improve the body satisfaction in tradi-tional weight reduction programs. However, given the nature ofthis research that does not include a followup study, the obtainedresults are preliminary only.

Index Terms—Binge eating disorder (BED), clinical psychology,obesity, virtual reality (VR).

I. INTRODUCTION

I started gaining weight about age thirty when I started havingfinancial problems…I’m now forty years old and I weigh

over 300 pounds. I binge continuously all day long. I can’t con-trol myself. I’ve stopped seeing friends and I spend my timealone—eating.” This quotation, reported by Nash in his recentbook on eating disorders [1, p. 3] was made by Peter, a bingeeating disorder (BED) patient. This disturbance is character-ized by ingestion of a large amount of food in a discrete pe-riod of time (about 2 h) and loss of control without compen-

Manuscript received January 10, 2001; revised April 15, 2002. This work wassupported by the Commission of the European Communities (CEC) and by theIST Programme under Project VEPSY UPDATED, IST-2000–25323.

G. Riva is with the Applied Technology for Neuro-Psychology Laboratory,Istituto Auxologico Italiano, Verbania, Italy and is also with the Departmentof Psychology, Catholic University of the Sacred Heart, 20123 Milan, Italy(e-mail:[email protected]).

M. Bacchetta and M. Baruffi are with the Applied Technology for Neuro-Psychology Laboratory, Istituto Auxologico Italiano, 28900 Verbania, Italy.

E. Molinari is with the Laboratorio Sperimentale di Ricerche Psicologiche,Istituto Auxologico Italiano, 28900 Verbania, Italy and is with the Departmentof Psychology, Catholic University of the Sacred Heart, 20123 Milan, Italy.

Publisher Item Identifier 10.1109/TITB.2002.802372.

satory behavior (vomiting, use of laxatives) typical of bulimianervosa. Unofficially termed “compulsive overeating” or “emo-tional eating” [1], BED affects nearly 2% of the population [2].BED is often accompanied by overweight: between 25 and 35%of those who seek treatment for obesity have BED [3], [4]. Re-search on comorbidity indicates a substantial degree of psycho-logical disturbance in BED beyond the BED criterion of markeddistress [4]. In particular, perceived pressure to be thin fromfamily, peers, friends, and dating partners is a key factor for thedevelopment of the disturbance. This pressure can produce inthe patient a poorly developed sense of self, coupled with be-liefs of ineffectiveness in dealing with others [5], [6].

Probably this situation can be explained by the commonbelief that the best way to improve one’s body image is to loseweight. Indeed, weight reduction is probably the most-usedremedy—even if it is very difficult to manage—for body imagedissatisfaction. As reported by Rosen [7], the most commonreason for attempting to lose weight in women is the desire toimprove physical appearance.

However, recent studies have questioned this belief: dietaryintervention, even if accompanied by significant weight loss,may be ineffective in reducing total body dissatisfaction [8],[9]. For instance, Cashet al. [10] found that obese subject whohad lost weight were similar in appearance evaluation to a cur-rently overweight sample and more distressed than a group ofnonobese subjects.

Given the importance of body image satisfaction for thequality of life of BEDs, these findings argue for the potentialbenefits of treatment strategies for improving appearance satis-faction for BED individuals, regardless of the success of theirweight-management efforts [11]. Unfortunately, obesity andBED researchers have not added yet body image interventionsin their programs. In a recent review on the behavioral obesitytreatment literature Rosen [7] did not find any study includingpsychological techniques specifically designed to modify bodyimage.

There are two different approaches to the treatment ofbody image disturbances that are actually used from leadingresearchers and clinicians: cognitive-behavioral and feministmethodologies [11]. Even if both methods are actually used bymany therapists, the treatment of body image disturbance ismoving “in the area of multicomponent intervention methods”[11, p. 322]. A recent model proposed by Thompsonet al. [11]underlines the complexity behind the development of bodyimage disturbances.

1089-7771/02$17.00 © 2002 IEEE

RIVA et al.: VR-BASED MULTIDIMENSIONAL THERAPY IN BINGE EATING DISORDERS 225

In this study we propose an integrated approach to the treat-ment of body image disturbances in BEDs based on an excitingnew technology: virtual reality (VR). Such choice would makeit possible to use the psychophysiological effects induced bythe virtual experience on the body schema for therapeutical pur-poses [12], [13].

Previous studies have suggested that VR can be effective inclinical treatment [14]–[18]. One of the main advantages of avirtual environment (VE) for clinical psychologists is that it canbe used in a medical facility, thus avoiding the need to ventureinto public situations. In fact, in most of the previous studies,VEs were used in order to simulate the real world.

However, it seems likely that VR can be more than a tool toprovide exposure and desensitization [19]. As noted by Glantzet al., “VR technology may create enough capabilities to pro-foundly influence the shape of therapy” [20, p. 92]. In partic-ular, they expect that VR may enhance cognitive therapy.

In practically all VR systems the human operator’s normalsensorimotor loops are altered by the presence of distortions,time delays, and noise [21]. Such alterations, that are introducedunintentionally and usually degrade performance, affect bodyperceptions, too. The somesthetic system has a proprioceptivesubsystem that senses the body’s internal state, such the positionof limbs and joints and the tension of the muscles and tendons.Mismatches between the signals from the proprioceptive systemand the external signals of a virtual environments alter bodyperceptions and can cause discomfort or simulator sickness [22].Perceptual distortions, leading to a few seconds of instabilityand a mild sense of confusion, were also observed in the periodimmediately following the virtual experience.

Such effects, attributable to the reorganizational and recon-structive mechanisms necessary to adapt the subjects to the qual-itatively distorted world of VR, could be of great help duringthe course of a therapy aimed at influencing the way the bodyis experienced [23], because they lead to a greater awareness ofthe perceptual and sensory/motorial processes associated withthem. When a particular event or stimulus violates the informa-tion present in the body schema (as occurs during a virtual expe-rience), the information itself becomes accessible at a consciouslevel [24]. This facilitates the process of modification and, bymeans of the mediation of the self (which tries to integrate andmaintain the consistency of the different representations of thebody), also makes it possible to influence body image.

In previous studies, a preliminary version of this approach,called virtual environment for body image modification(VEBIM) [11, p. 322–325], was tested on nonclinical subjects[12], [13], [25] and clinical subjects [26] in uncontrolledstudies. The results indicated that the virtual experience in-duced in the subjects a significantly more realistic view of theirbody.

Starting from these assumptions, this paper describes thecharacteristics and preliminary controlled clinical evaluation ofthe virtual reality for eating disorders modification (VREDIM),a VR-based treatment to be used for body image therapy inBEDs. The approach was developed to support an inpatientweight-reduction program.

II. M ETHOD

A. Subjects

Subjects were consecutive patients seeking treatment atthe Eating Disorder Unit of the Istituto Auxologico Italiano,Verbania, Italy.

The individuals included were 20 women (Mean weight:114.94 25.04 kg; mean height: 163 6.32 cm; mean bodymass index (BMI): 43.21 9.15) between the ages of 18 and45 years, who met DSM IV [27] research criteria for BEDs fora minimum of six months as determined by an independentclinician on clinical interview.

Potential participants were excluded if they were taking an-tidepressant medication or any medication that might influenceweight, if they abused drugs or alcohol, if they had a currentmajor psychiatric condition such as a psychosis, if there was ahistory of purging within the previous six months, or if theirBMI was below 30. The latter criterion excluded individualswho did not require treatment for overweight.

The sample was randomly divided into two groups: the exper-imental group (Mean age: 30.506.72; mean weight: 120.0628.34 kg; mean height: 165 7.17 cm; mean BMI: 44.0710.10) and the control group (Mean age: 30.106.95; meanweight: 109.82 21.48 kg; mean height: 1614.91 cm; meanBMI: 42.35 8.55).

To ensure the equivalence of the two groups, we examined thedifferences among them on weight, BMI, and all the pretherapyassessment measures by using one-way analysis of variance. Nosignificant differences between groups were obtained on anyof the measures, and therefore, it can be assumed that the twogroups were equivalent at the beginning of the intervention.

B. Measures

Subjects were assessed by one of three independent assess-ment clinicians who were not involved in the direct clinical careof any subject. They were two M.A.-level chartered psycholo-gists and a Ph.D.-level chartered psychotherapist. All the subjectwere assessed at pretreatment and upon completion of the clin-ical trial.

The following psychometric tests were obtained at entry tothe study:

• Italian version of the Minnesota Multiphasic PersonalityInventory 2–MMPI 2 [28];

• Italian version of the Eating Disorders Inventory 2–EDI 2[29].

In Table I, we report the mean EDI 2 and MMPI 2 scoresobtained by the two groups.

Moreover, the following psychometric tests were adminis-tered at each assessment point (entry to the study, end of thetreatment):

• Italian version [30] of the dieter’s inventory of eatingtemptations DIET [31]. The inventory has 30 items,each presenting a situational description along with acompetent response. The subject rates the percentageof time he or she would behave as described in similarsituations. A total score and six subscales are computed.The subscales are resisting temptation, positive social,


TABLE IMEAN MMPI 2 AND EDI 2 SCORES IN THE TWOGROUPS

food choice, exercise, overeating and negative emotions.The inventory was originally designed for use with obeseindividuals who are trying to lose weight in behavioralweight loss programs, but, according to the authors, itmay be useful for identifying situations most likely totrigger loss of control by bulimic patients [31].

• Italian version [32] of the state-trait anxiety inventory(STAI) [33].

• Italian version [34] of the assertion inventory (AI) [35].• Italian version [36] of the weight efficacy life-style ques-

tionnaire (WELSQ) [37]. The WELSQ is composed by 20items that measure the confidence of the subjects aboutbeing able to successfully resist the desire to eat using aten-point scale ranging from 0 (not confident) to 9 (veryconfident). The questionnaire was used to predict bothacute change and long-term maintenance of weight lossacross a range of ages in men and women [37].

• Italian version [38] of the University of Rhode Islandchange assessment scale (URICA) [39], [40]. The URICAconsists of 32 items designed to measure four stages ofchange in psychotherapy:precontemplation, contempla-tion, action andmaintenance. Each item is scored usinga five-point Likert-type format: higher scores indicategreater agreement with statements. The URICA wasoriginally developed for use with clients in psychotherapyreporting on their problems [40]. However, the instrumentis also used for measuring readiness to change acrossa wide variety of problem behaviors, expecially theaddictions including smoking cessation, alcohol use, andcocaine use [39].

• Italian version [41] of the body satisfaction scale (BSS)[42]. The scale consists of a list of 16 body parts, half in-

volving the head (above the neck) and the other half in-volving the body (below the head). The subjects rate theirsatisfaction with each of these body parts on a seven-pointscale: the higher the rating, the more dissatisfied the indi-vidual. A total score and three subscale scores are com-puted for head, torso, and limbs items [41]. The scale wasdesigned for work in health-related fields. In particular,the scale was used by the authors to assess body dissat-isfaction in eating disorders, to monitor changes in bodysatisfaction in subjects undergoing surgical treatment forbreast cancer, and to determine the psychological effectsof either maxillary or mandibular joint surgery [41].

• Italian version [43] of the body image avoidance question-naire (BIAQ) [44]. The BIAQ is 19-item self-report ques-tionnaire on avoidance of situations that provoke concernabout physical appearance, such avoidance of tight-fittingclothes, social outings, and physical intimacy. In partic-ular, the questionnaire measures the avoidance behaviorsand grooming habits associated with negative body image[44]. The questionnaire uses a six-point scale to rate fre-quency of behavior: never, rarely, sometimes, often, usu-ally, and always. A total score and four subscales are com-puted for: clothing, social activities, eating restraint, andgrooming/weighing.

• Figure rating scale (FRS) [45], a set of nine male andfemale figures which vary in size from underweight tooverweight.

• Contour drawing rating scale (CDRS) [46], a set of ninemale and female figures with precisely graduated incre-ments between adjacent sizes.

In the last two tests subjects rate the figures based on the fol-lowing instructional protocol: 1) current size and 2) ideal size.


Fig. 1. VR display.

The difference between the ratings is called theself-ideal dis-crepancy scoreand is considered to represent the individual’sdissatisfaction.

The findings of Keetonet al. [47] support the usefulnessof the self-ideal discrepancy score in the assessment of bodyimage, as it was shown to relate to other body-image indexesand other clinically relevant measures. All the scales have goodtest–retest reliability [42], [44].

C. Treatment

For the VR sessions, the VREDIM was used. VREDIM isan enhanced version of the original VEBIM immersive virtualenvironment, previously used in different preliminary studies onclinical [26] and nonclinical subjects [12], [25].

VREDIM is implemented on a Thunder 866/C VR systemby VRHealth.com, San Diego, CA (http://www.vrhealth.com).The Thunder 866/C is a Pentium III based immersive VR system(866mhz, 128 mega RAM, graphic engine: Matrox MGA 45032Mb WRam) including a head-mounted display (HMD) sub-system (see Fig. 1). The HMD used is the Glasstron from SonyInc. The Glasstron uses LCD technology (two active matrixcolor LCDs) displaying 180 000 pixels each. Sony has designedits Glasstron so that literally no optical adjustment at all is re-quired, aside from tightening a two ratchet knobs to adjust forthe size of the wearer’s head. There is enough “eye relief” (dis-tance from the eye to the nearest lens) that it is possible to wearglasses under the HMD.

The motion tracking is provided by Intersense through itsInterTrax 30 gyroscopic tracker (Azimuth:180 ; Elevation:

80 , Refresh rate: 256 Hz, Latency time: ms ).We used a two-button joystick-type input device to provide

an easy way of motion: pressing the upper button the operatormoves forward, pressing the lower button the operator moves

backward. The direction of the movement is given by the rota-tion of operator’s head.

A detailed description of the clinical approach used in thedifferent 3-D Healing Experiences is reported in Table II. Thevirtual environment is composed of seven 3-D Healing Experi-ences (zones), each one individually used by the therapist duringa 50-min session with the patient (see Table III).

The first 3-D Healing Experience is used to assess anystimuli that could elicit abnormal eating behavior. In particularthe attention is focused on the patient’s concerns about food,eating, shape, and weight. This assessment is normally partof the temptation exposure with response prevention protocol[48]. At the end of the first 3-D Healing Experience, thetherapist uses the miracle question, a typical approach usedby the solution- focused brief therapy [49], [50]. According tothis approach, the therapist asks the patient to imagine whatlife would be like without her/his complaint. Answering thisquestion in writing, the patient constructs her/his own solution,which then guides the therapeutical process [51]. Accordingto deShazer [51] this approach is useful for helping patientsestablish goals, that can be used to verify the results of thetherapy. Using VR to experience the effects of the miracle,the patient is more likely not only to gain an awareness of herneed to do something to create change but also to experience agreater sense of personal efficacy.

The next 3-D Healing Experiences are used to assess andmodify:

• Symptoms of anxiety related to food exposure. Thisis done by integrating different cognitive-behavioralmethods (see Table II): countering, alternative interpre-tation, label shifting, deactivating the illness belief andtemptation exposure with response prevention [13], [48].

• Body experience of the subject. To do this the virtual envi-ronment integrated the therapeutic methods (see Table II)used by Butter and Cash [52] and Wooley and Wooley


TABLE IITHERAPEUTICAL METHODSINTEGRATED IN VREDIM

TABLE III3-D HEALING EXPERIENCESINCLUDED IN VREDIM

[53]. In particular, in VREDIM we used the virtual envi-ronment in the same way as guided imagery [54] is usedin the cognitive and visual/motorial approach.

In all the sessions, the therapists follow the Socratic style:they use a series of questions, related to the contents of thevirtual environment, to help clients synthesize information andreach conclusions on their own.

The experimental group received seven sessions of VREDIMplus a low-calorie diet (1200 cal/day) and physical training(30 min of walking two times a week as a minimum).

For the control group, the inpatient treatment consisted of thesame low-calorie diet (1200 kcal/day) and physical training asthe experimental group, plus psycho-nutritional groups (threetimes a week) aimed at helping the patients to understand theimportance of their lifestyle and to modify unhealthy and de-structive behavior patterns. The psycho-nutritional groups werebased on the cognitive-behavior approach [55] and focused onteaching patients methods for improving their stress manage-ment, problem-solving, and eating.

The treatment for both groups lasted approximately 6.5 weeks(mean length for the experimental group: 6.6 0.4 weeks;mean length for control group: 6.4 0.5 weeks).


TABLE IVMEAN BIAQ, BSS, CDRS, FRS, DIET, STAI AI, WELSQ,AND URICA SCORESBEFORE ANDAFTER TREATMENT (VR GROUP)

In order to make sure that therapists adhered to the specifictechnique in each therapy, we gave two independent judges (se-nior clinical psychologists who were not involved in the study)samples of recorded sessions of both techniques. There was noinstance in which the judges could not identify correctly thetherapy to which a certain session belonged.

The study received ethical approval by Ethical Committee ofthe Istituto Auxologico Italiano. Before starting the trial, thenature of the treatment was explained to the patients and herwritten informed consent was obtained.

D. Statistical Analysis

A power calculation was made to verify the possibility of ob-taining statistically significant differences both between the twogroups (independent measures), and the pre– and posttreatmentscores (repeated measures). Given the low/medium statisticalpower, due to the relatively small number of subjects and thehigh standard deviation, we decided to use the exact methods,a series of nonparametric statistical algorithms developed bythe Harvard School of Public Health, that enable researchers tomake reliable inferences when data are small, sparse, heavilytied, or unbalanced [56]

The exact method used to compare the mean scores—both forrepeated and independent measures—was the marginal homo-geneity test [57].

III. RESULTS

In Table IV, we report the means and standard deviations forthe tests’ scores obtained by the VR group before and afterthe therapy. The marginal homogeneity test reported significantdifferences in the BIAQ clothing and grooming scores, in theCDRS Ideal score, in the DIET overeating score, in the STAItotal score, in the AI and ability scores, in the WELSQ totalscore and in the URICA total, action, and maintenance scores.

These results indicate that the therapy was able improve theoverall psychological status of the patients.

First, the therapy reduced their level of body dissatisfation.In particular, the treatment was able to induce a more realisticexpectation about their ideal body. Second, the therapy reducedthe level of anxiety in the patients. Finally, they increased theirself-efficacy and their motivation for change.

This reflected also on the behavior of the subjects. In fact,they:


TABLE VMEAN BIAQ, BSS, CDRS, FRS, DIET, STAI AI, WELSQ,AND URICA SCORESBEFORE ANDAFTER TREATMENT (CONTROL GROUP)

• were less concerned about social judgement: pa-tients improved their social activity, were less worriedabout their weight, and reduced the use of disguisingclothes;• reduced overeating: in particular, no binge episodes

were reported after the first week of therapy.No subjects experienced simulation sickness.In Table V, we report the means and standard deviations for

the tests’ scores obtained by the control group before and afterthe therapy. The only significant change was in the AI anxietyscore. However, this reduction in the anxiety level was not con-firmed by the STAI score.

Then, we compared the differences pre- and posttherapy inthe mean BIAQ, BSS, CDRS, FRS, DIET, STAI AI, WELSQ,and URICA scores between the two groups (Table VI). Thestatistical tests showed significantly higher differences in theVR group for the following scales: BIAQ clothing, DIETovereating, STAI total score, AI ability score, WELSQ totalscore, URICA action, and maintenance score.

These findings showed that VREDIM was more effectivethan the traditional low-calorie diet plus cognitive-behav-ioral nutritional groups in improving body satisfaction and

in reducing overeating and the anxiety level of the patients.Moreover, VREDIM induced an improved level of self-efficacyin the patients associated with a higher motivation for change.

All the 20 patients had achieved complete cessation of bingeeating—defined as no binge eating for the past two weeks—atthe end of the treatment. This result was maintained in the firstmonth after the end of the therapy.

IV. DISCUSSION

The first interesting result of this study is the lack of side ef-fects and simulation sickness in our samples after the experiencein the virtual environment, confirming the possibility of usingVREDIM for body image treatment.

Although there is much potential for the use of immersive VRenvironments in clinical psychology, some problems have lim-ited their application in this field. Some users have experiencedside-effects during and after exposure to VR environments [58].The symptoms experienced by these users are similar to thosewhich have been reported during and after exposures to simu-lators with wide field-of-view displays [59]. These side-effectshave been collectively referred to as “simulator sickness” [60]


TABLE VIMEAN DIFFERENCES IN THEBIAQ, BSS, CDRS, FRS, DIET, STAI AI, WELSQ,AND URICA SCORES(BEFORE ANDAFTERTREATMENT)

and are characterized by three classes of symptoms: ocular prob-lems, such as eyestrain, blurred vision, and fatigue; disorien-tation, and balance disturbances; nausea. Exposure duration ofless than 10 min to immersive VR environments has been shownto result in significant incidences of nausea, disorientation, andocular problems [61].

The lack of side effects and simulation sickness in our sampleis even more interesting given the sample used. In fact, femalestend to be more susceptible to motion sickness than males [62].

Our experience with the use of ECT suggests that thistreatment is able in reducing binge frequency and comorbidpsychopathology in the short term. Moreover, even if nodifferences were found in the capacity of reducing binge eating,VR treatment was more effective than the traditional cognitive-behavioral psycho-nutritional groups in reducing weight andin improving the overall psychological state of the patients. Inparticular, the VR treatment (VREDIM) was more effectivethan the traditional low-calorie diet plus cognitivebehavioralnutritional groups in improving body satisfaction and in re-ducing overating and the anxiety level of the patients. Finally,the VR treatment induced an improved level of self-efficacy inthe patients associated to an higher motivation for change.

Its multidisciplinary approach seems to be suitable to the pe-culiar characteristics of body image disturbances in obesity. Inparticular VREDIM was effective in dealing with two key fea-tures of these disturbances not always adequately addressed bycognitive-behavioral therapy: body experience disturbances andself-efficacy.

First, VREDIM allows the integration of different methods(cognitive, behavioral, and visual-motorial) commonly used inthe treatment of body experience disturbances within a virtualenvironment [23]. In particular, VREDIM integrates the cog-nitive methods of countering, alternative interpretation, labelshifting, and deactivating, the behavioral method of temptationexposure with response prevention and the visual motorial ap-proach (see Table II) using the virtual environment in the sameway as images in the well-known method of guided imagery[54]. According to this method the therapist, after introducing aselected image, encourages the patient to associate to it in pic-tures, rather than in word, and to give a detailed description ofthem.

A choice of this type makes it possible both to evoke latentfeelings, and to use the psychophysiological effects provokedby the experience for therapeutic purposes [23], [25]. In practi-


cally all VR systems, the human operator’s normal sensorimotorloops are altered by the presence of distortions, time delays, andnoise [21]. Such effects, attributable to the reorganizational andreconstructive mechanisms necessary to adapt the subjects tothe qualitatively distorted world of VR, could be of great helpduring the course of a therapy aimed at influencing the way thebody is experienced [23], because they lead to a greater aware-ness of the perceptual and sensory/motorial processes associ-ated with them.

As noted by Glantz [20, p. 96], one of the main reasons it isso difficult to modify patients’ attitudes toward their body is thatchange often requires a prior step—recognizing the distinctionbetween an assumption and a perception: “Until revealed to befallacious, assumptions constitute the world; they seem like per-ceptions, and as long as they do, they are resistant to change. Weanticipate using VR to help people in distress make the distinc-tion between assumptions and perceptions.”

This is particulary true for body experience. When a partic-ular event or stimulus violates the information present in thebody schema (as occurs during a virtual experience), the infor-mation itself becomes accessible at a conscious level [24]. Thisfacilitates the process of modification and, by means of the me-diation of the self (which tries to integrate and maintain the con-sistency of the different representations of the body), also makesit possible to influence body image.

Second, using VREDIM therapists can improve the self-ef-ficacy and motivation for change in their patients. Accordingto Prochaska and DiClemente [63], it is possible to identifyfive stages of change that people face in altering problematicbehavior. These stages can be considered predictable and stablesubprocesses within the therapeutic process. The five stagesare: precontemplation, contemplation, determination, actionand maintenance/relapse.

In particular, a stage of change is critical for the therapy ofbody image disturbances: contemplation. Contemplation is aparadoxical stage of change, since the patient is open to thepossibility of change but is stopped by ambivalence. The char-acteristic style of the contemplator is, “yes, but . . .”. Two keytechniques are usually in facilitating a shift from the contem-plation stage to the determination stage of change [50]. Thefirst technique is the use of themiracle question, a typical ap-proach used by the solution-focused brief therapy [49], [50].The miracle question is used to help the client identify how herlife would be different if her eating disorder were miraculouslygone. The second technique is the search for exceptions: situa-tions in which the patient has been able to manage the problem-atic eating behaviors more successfully.

Using the VR sessions to experience the effects of the mir-acle and the successful situations, the patient is more likelynot only to gain an awareness of her need to do something tocreate change but also to experience a greater sense of personalefficacy.

According to Vitouseket al. [64], another well-suited ap-proach to face denial and to support self-efficacy is theSocraticmethod. In this method, the therapist uses different questions tohelp patients synthesize information and reach conclusions ontheir own. Usually the therapist poses hypothetical, inverse, andthird-person questions [64]: for example, would the significance

of body shape change if the obese patient became stranded ona desert island? Would a patient swallow a magic potion thatcould remove her fear of overweight?

VR is well suited to this approach, for its ability of immersingthe patient in a real-like situation that she/he is forced to face.Infact, the key characteristic of VR is the high level of con-trol of the interaction with the environment without the con-strains usually found in real life. VR is highly flexible and pro-grammable. It enables the therapist to present a wide variety ofcontrolled stimuli and to measure and monitor a wide variety ofresponses made by the user [65]. Both the synthetic environmentitself and the manner in which this environment is modified bythe user’s responses can be tailored to the needs of each clientand/or therapeutic application. Moreover, VR is highly immer-sive and can cause the participant to feel “present” in the virtualrather than real environment. It is also possible for the psychol-ogist to follow the user into the synthesised world.

The advantages of a VR-based Socratic method are clear. Itminimizes distortion in self report, since there is no script forconforming clients to parrot or oppositional clients to reject; atypical behavior of anorexic individuals.

Moreover, it circumvents power struggles because the ther-apist can be invisible to the patient and presents no direct ar-guments to oppose. Finally, evidence is more convincing andconclusions better remembered because they are one’s own. Asnoted by Miller and Rollnick [66, p. 58], people are “more per-suaded by what they hear themselves say than by what otherpeople tell them.”

As we have seen before, change often requires the recognitionof the distinction between an assumption and a perception [19].By using VR, the therapist can actually demonstrate that whatlooks like a perception does not really exist. This gets acrossthe idea that a person can have a false perception. Once this hasbeen understood, individual maladaptive assumptions can thenbe challenged more easily.

Usually the traditional body-image treatment involves a cog-nitive/behavioral or a feminist therapy that require many ses-sions. The possibility of inducing a significant change in bodyimage and its associated behaviors using a VR-based short-termtherapy (seven biweekly sessions) can be useful to improve thebody satisfaction in traditional weight reduction programs.

As such, VREDIM can be considered as a multifactorial treat-ment package aimed at breaking through the “resistance” totreatment in clinical subjects [67], [68]. Nevertheless, an alter-ation of the body image toward a more realistic “proportion”might also be decisive for the long-term outcome of the weightreduction therapy.

Of course, given the nature of this research that does not in-clude a follow-up study, the obtained results are preliminaryonly. Moreover, the cost of the VR system used in the study isabout $7000. This price, even if affordable for departments orhospitals, is still high for a single therapist, especially withouta clear cost/benefit ratio. From a clinical view point the mainissues that we have to address in a systematic way in the futureare:

• further testing of VREDIM in controlled clinical trials, bycomparing it with different approaches (e.g., interpersonaltherapy);


• a followup study to check the long-term efficacy of thetherapy.

We have already planned an extention of the study as a partof the “Telemedicine and portable virtual environments for clin-ical psychology” European Community-funded research project(IST-2000–25 323).

ACKNOWLEDGMENT

The authors wish to thank E. Borgomainerio, L. Petroni,S. Rinaldi, and F. Vincelli for their support and contributions.

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Giuseppe Rivareceived the Ph.D. degree in socialpsychology from the Catholic University of Milan,Milan, Italy, in 1995.

He is a Research Professor of General Psychologywith the Catholic University of Milan, Milan, Italy,and the Head Researcher at the Applied Technologyfor Neuro-Psychology Laboratory, Istituto Auxo-logico Italiano, Verbania, Italy.

Monica Bacchetta received the Psy.D. degree inclinical psychology from the Scuola di Specializ-zazione Quadriennale ASIPSE, Milan, Italy, in 2000.

She is a Senior Researcher with the AppliedTechnology for Neuro-Psychology Laboratory,Istituto Auxologico Italiano, Verbania, Italy.

Margherita Baruffi received the Psy.D. degree inclinical psychology from the Scuola di Specializ-zazione Quadriennale ASIPSE, Milan, Italy, in 2000.

She is a Researcher with the Applied Technologyfor Neuro-Psychology Laboratory, Istituto Auxo-logico Italiano, Verbania, Italy.

Enrico Molinari received the Psy.D. degree in clinical psychology from theCatholic University of Milan, Milan, Italy, in 1986.

He is an Associate Professor of Clinical Psychology with the Catholic Uni-versity of Milan, Milan, Italy, and the Head of the Clinical Psychology Service,Istituto Auxologico Italiano, Verbania, Italy.

Documents

Virtual-reality-based multidimensional therapy for the treatment of body image disturbances in binge eating disorders: a preliminary controlled study