Research Highlights / Full Story

The Challenge

A man arrested for domestic violence attends a crowded group therapy session on anger management. He comes home drunk and bristles when his wife accuses him of drinking. Their children standing in the doorway watch the argument escalate into shoving and swearing. Their father hits their mother; they absorb the violence.

A 15-year-old boy with autism spectrum disorder stands in line at his high school cafeteria, avoiding eye contact and conversation with his classmates as if his life depended on it. He wishes the lunch ladies would stop telling him to have a good day.

Effective mental and behavioral health treatment can help people with substance abuse and aggressive tendencies end their addiction and learn healthy conflict resolution skills; likewise, young people with autism spectrum or obsessive-compulsive disorders can learn how to work with their problems and achieve their goals.

Two projects at RIT's Institute of Health Sciences and Technology are combining interactive media with therapy to teach people how to change their thoughts and behavior. RIT professors Caroline Easton and Laurence Sugarman are forward-thinking faculty whose projects are laying the foundation for a defining niche that could set the Institute apart from other centers. Easton and Sugarman's respective research taps RIT's strengths in gaming and medical illustration to add a virtual component to mental and behavioral health treatment.

"We're interested in progressive, preventive approaches to keeping people healthy," says Daniel Ornt, dean and vice president of the Institute of Health Sciences and Technology, part of the RIT-Rochester General Health System Alliance. "We're directing our efforts toward health and wellness, and introducing technologies as new approaches to helping people improve their health. Behavioral/mental health is a key area for achieving good health, so we are excited about growing educational programs and research in that area."

Addiction, Violence, and Cyber Therapy

Easton, a forensic clinical psychologist in the College of Health Sciences and Technology and a 1990 alumna with a BS in biotechnology, is a leader in clinical forensic psychology. Her research treats the combustible combination of co-occurring substance abuse and family/intimate partner violence, which, until recently, had been treated separately.

The model Easton developed in 1997 and refined at the Forensic Drug Diversion Clinic she established at Yale University Medical Center in 2003 targets anger problems and aggression with cognitive behavioral therapy, a proven method for treating substance abuse, depression, and anxiety. In her method, therapy helps teach people health coping skills to reduce the maladaptive behaviors of substance use and aggression. Healthier coping skill sets are taught to clients to help them cope with cravings, learn more pro-social communication skills and anger controls. The healthier the skills sets, the better the treatment outcomes are and hence, less family conflict.

"The one-size-fits-all approach has been used for 30 years or so, and it hasn't changed," Easton says. "It costs $5.8 billion a year in taxpayer money, not to mention damage to families. Children witnessing untreated mental health and behavioral health issues often end up as victims or as offenders themselves."

The mental and behavioral health issues Easton treats are global health concerns. Her method has attracted international attention from colleagues also struggling to treat family violence among clients with addictions. Collaborators in Brazil and Great Britain, as well as colleagues in the United States, are adopting her model for treating individuals with co-occurring substance abuse and domestic and intimate-partner violence issues.

Gail Gilchrist, head of the Center for Applied Social Research at the University of Greenwich in London, is implementing Easton's method in eight ambulatory clinics across London. Gilchrist visited RIT in March to give the keynote talk at the conference Treating Family Violence as a Contagious Disease: Moving Beyond a One-Size-Fits-All Treatment Approach, sponsored by RIT's College of Health Sciences and Technology and the Office of Research.

Easton is exploring the potential of virtual reality tools to treat and educate individuals with substance abuse and aggression issues through role playing and modeling positive behavior. Exhibits at the conference in March displayed virtual reality, cyber and human visual- ization tools that RIT medical illustration students are developing with Easton. Their interactive software supplements Easton's integrative model of care for assessing and treating substance abuse, domestic violence, and the interaction between the two.

Easton points to "Al-Virt" as an example. The virtual coach, created by graduate student Alan Gesek, will help clients improve their nonverbal and verbal communication skills. The customizable avatar is an empathetic character and a positive role model that teaches healthy communication skills through role- playing exercises and realistic vignettes. Facial recognition software is layered into the program to enable the cyber coach/avatar to respond to a client's emotional cues. Easton predicts that virtual role playing will be more palatable for patients who find standard therapeutic role play with the therapist as uncomfortable.

"Having this tool helps shape and reinforce healthy behavior," she says. "The clients are video- taped acting out behavior, and they're shown what they look like doing it. Then they're shown a healthy way of resolving the same conflict. It really helps them even more. It's based on social learning theory." Her multidisciplinary research team of faculty and students includes RIT professors James Perkins, Richard Doolittle, Glenn Hinz, Shaun Foster, and Steve Jacobs; and students from the medical illustration program, Valerie Altounian, Alan Gesek, Teraisa Chloros, Timothy Fitzgerald, and Nirja Desai. The faculty-student team creates interactive role-playing scenarios grounded in Easton's evidence-based research. The students' technological skills merge and glue the storyboard together, Easton says.

"I think virtual reality tools are the future," Easton says. "Human visualization, cyber, virtual tools, and gaming are all going to be an important part coupled with our best practice procedures. This is where the College of Health Sciences and Technology is going to be great. It's about furthering these tools and coupling them with our patient interaction."


Another project that taps strengths of the Institute of Health Sciences and Technology and the B. Thomas Golisano College of Computing and Information Sciences has the potential to advance RIT in the field of therapeutic interactive gaming, or "games for health," a category within the genre of "serious games."

MindGamers is a role-playing video game platform in development at RIT's Center for Media, Arts, Games, Inter- action and Creativity, or MAGIC. The first application, "MindGamers in School," is designed to teach calming and self- regulating skills to teenagers with autism spectrum and obsessive-compulsive disorders. A patient will play the game during therapy sessions to learn to control stress physiology and overcome repetitive thoughts and behaviors.

MindGamers is a collaboration among Sugarman, director of the Center for Applied Psychophysiology and Self- Regulation at RIT's Institute of Health Sciences and Technology and clinical associate professor in pediatrics at the University of Rochester School of Medicine and Dentistry; Stephen Jacobs, associate professor of RIT's School of Interactive Games and Media; and Robert Rice Jr., director of clinical internships in the Mental Health Counseling Program at St. John Fisher College.

Sugarman anticipates having a playable first-level game by fall. "I expect MindGamers should be ready for clinical trials as a game versus standard therapy or medication, even, by early 2014."

Seed funding Sugarman and Jacobs won from the Effective Access Technology Program offered by RIT's Office of the Vice President for Research supports student researchers from the School of Interactive Games and Media in the Golisano College of Computing and Information Sciences. The student team works with Jacobs to build environments and scenarios to reflect the needs of potential players. Feedback from clients at Easter Seals Diagnostic and Treatment Center in Rochester, which works with Sugarman and Rice, is driving the content of the game.

"My clients want something that fits with modern video games," Rice says. "That includes graphics and game play. Many of my clients are attracted to games involving character creation."

Creating the game with feedback from potential players gives the team reassurance that MindGamers will reach and meet the needs of teens with autism, anxiety, and obsessive-compulsive disorders.

"In mental health games, overall, we are enabling the players to tell their own story," Jacobs says. "That's what we do with MindGamers. We provide a place for the therapist and player to customize and build on."

MindGamers uses three avatars for patients to customize: one to resemble themselves, and two corresponding "imps" to externally reflect the patients' goals and problems as they move through scenes simulating their daily life.

"The goal-based imp is the player's ideal version of himself, equipped with items the patient and therapist have named that remind them of goals they are trying to reach or the process they are trying to take to reach their goals," Jacobs says. "The problem-based imp is how they envision their current problem."

The therapist and player set triggers for game play. For someone suffering from germophobia, that environment might include messy trash cans. Choosing to avoid the receptacles or compulsively "fix them" in response to stress gets in the way of meeting their goals for the game, Jacobs explains.

"The movement has really just begun," Rice says. "We are just learning how and why people are so engaged and, perhaps, changed by playing video games."

Biofeedback data is collected through sensors attached to the player's fingers and strapped around his or her waist. The sensors monitor four inputs—sweat gland activity, body temperature, heart rate, and breathing—as the player navigates the environment. The information helps patients connect their physiological changes to stressful situations and, through therapy, learn calming techniques to manage and reduce stress.

The biofeedback device uses a product made by MindMedia BV, which specializes in physiological monitoring and feedback products for researchers, clinicians, and health care professionals. The Netherlands-based company loaned the team the NeXus-10 Biofeedback hardware and Biotrace software to create its prototype game. The medically approved biofeedback device and physiological inputs will generate data to measure and compare outcomes.

"MindGamers is about self-regulation. That's a major point of the Center for Applied Psychophysiology and Self- Regulation," Sugarman says. "It's about balancing health care with what people can do for themselves. That's both fundamental and cost-effective."