Jiyoon Moon, B.A., Jang-Han Lee, Ph.D. Department of Psychology, Chung-Ang University

1. Development of Virtual Aversive Environment: Preliminary Study of Covert Sensitization for Alcohol Craving CYBERTHERAPY CONFERENCE 2008 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

2. Introduction Subjective cue-elicited reactions • Craving • Withdrawal symptoms • Drug-agonistic effect • Mood swings Cue Reactivity A classical conditioned response pattern that occurs when an addicted subject is exposed to drug-related stimuli Physiological reactions • Skin conductance • Heart Rate • Salivation • Body temperature • Brain activity Relapse

3. Introduction • Aversion Therapy (grounded in classical conditioning) Taste aversion learning (Garcia, 1955) UCS UCR UCS UCR repeatedly paired CS

4. Introduction • Covert Sensitization (Cautela, 1966) - Imagery based behavior aversion therapy - Verbal aversionprocedure 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 UCR + UCS

5. An Example Description Introduction 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)

6. 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) • Disadvantage • - Highly relying on individual’s ability of imagination • - Controlling covert stimuli would be solved with VR • Advantages of virtual reality in covert sensitization • - Helping increase one’s imagination • - Setting up standardized situation

7. Method • Preliminary survey to develop virtual environments and scenarios - Survey participants

8. Method • The open-ended questions → From the results of this survey, VR-covert sensitization scenarios were created Health risks Suffering from a hangover Family members

9. Method Virtual Hospital

10. Method Virtual Subway

11. 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

12. Method & Result_Experiment 1 • Procedure 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.

13. 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

14. Method_Experiment 2 Virtual CS for alcohol dependent patients • Participant - 2 alcohol dependent inpatients - drank 5 bottles of soju daily • Measurement - Self-report of craving (VAS) - Alcohol-Implicit Association Test (IAT) • Soju • Type of alcohol in Korea • 360ml • cheap, moderate-proof (21%), and popular

15. Method_Experiment 2 Alcohol-IAT Implicit Association Test (Greenwald, McGhee, & Schwartz, 1998) • Well-validated measurement for implicit attitudes - Alcohol consumption ← Stigmatized behavior <Operation of the IAT> d k positive negative Soft drink Alcohol Positive negative Soft drink Alcohol Positive Negative Alcohol Soft drink Alcohol Soft drink good Tequila bad Tequila Coke

16. Outline of the Research Method_Experiment 2 Questionnaire To see changes in attitudes to alcohol Alcohol-IAT Free Navigationof “Virtual City” Covert sensitization in “Virtual Subway” VR-Covert Sensitization • about 60 min, including • Introduction • Covert sensitization, • Interviews about feelings • Self-report questionnaire of craving Alcohol-IAT Questionnaire • demographic data, AUQ, History of (problematic) • alcohol drinking, craving, etc.

17. Result_Experiment 2 • Self-report data: Decreased AUQ, Craving, and Cue Craving How much do you want to drink?

18. Result_Experiment 2 • Implicit Attitude – not consistent • Interviews Y P

19. 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

20. Thank you for your attention Moderate drinking is good for your health