Neuroscience of Virtual Reality and Behavioral Change - Giuseppe Riva, Ph.D.

Neuroscience of VR and
Behavioral Change
Prof. Giuseppe Riva, Ph.D.
Università Cattolica del Sacro
Cuore, Milan, Italy
www.giusepperiva.com

Keynote Speaker
STANFORD, 3rd AIPBH, 2017
2
Giuseppe Riva, Ph.D.
Università Cattolica del Sacro Cuore, Milan, Italy
- Full Professor of General
Psychology
- Director of the Applied Technology
for Neuro-Psychology Lab. at
Istituto Auxologico Italiano, Milan
- European Editor of the scientific
journal “Cyberpsychology Behavior
and Social Networking”
- President of the International
Association of CyberPsychology,
Training, and Rehabilitation –
iActor

The open challenge for mental health
3
As underlined by this recent Nature
paper, we need better ideas and
tools for mental health.
My solution: Technology, and in
particular Virtual Reality

The goal of this presentation
4
The changing potential
of technology
Virtual Reality as
Positive Technology
Virtual Reality
In practice
Technology can help
us to change. How
and Why
Virtual Reality can
improve our personal
experience
A significant
application of VR: the
treatment of obesity
and eating disorders

The changing potential of technology
Technology can help us to change: How and Why

Technology is evolving… But its use?
6
One computer
for many users
One computer
for each user
Many computers
for each user
Thousands
computers for
each user
1960: Mainframe
Era
1980: Personal
Computer Era
2000: Mobility
Era
2020+: Ubiquity
Era
Source: Abigail Sellen, Yvonne Rogers, Richard Harper, Tom Rodden: Reflecting human values in the
digital age. Commun. ACM 52(3): 58-66 (2009)

Technology is not making us better…
7
Privacy
and
Security
Ethics and
Values
Multitasking And
Technostress

Open Challenge:
Using technology, and in particular virtual technologies, I want to
change people lives for better…
But what is change?

What is change?
9
Even if this question has
many possible answers
in general change
occurs through an
intense focus on a
particular instance or
experience (Wolfe,
2002).
By exploring this
experience as thoroughly
as possible, the patient
can relive all of the
significant elements
associated with it (i.e.,
conceptual, emotional,
motivational, and
behavioral) and make
them available for
reorganization.

§ Within this general model we have many specific
methods in clinical psychology:
§ the insight-based approach of psychoanalysis,
§ the schema-reorganization of cognitive therapy,
§ the functional analysis of behavioral therapy,
§ the interpersonal relationship focus of interpersonal
therapy,
§ and the enhancement of experience awareness in
experiential therapies.
What are the differences between them?

What is change
11
According to Safran and
Greenberg (1991), behind the
specific therapeutic approach
there are two different models of
change: bottom-up and top-down.
Bottom-up processing begins with
the focus on sensations and leads
to change at the behavioral and
conceptual level;
Top-down change usually involves
exploring and challenging tacit
rules and beliefs that guide the
processing of behavioral planning
and leads eventually to changes in
sensation processing.
Top Down
Bottom Up
Source: Safran, J.D. & Greenberg, L.S.(Eds.) (1991).
Emotion, psychotherapy and change. New York:
Guilford Press.

What is change
12
These two models of change are
focused on two different cognitive
systems (Kahneman, Nobel Prize
Lecture, 2002):
System 1 (Intuition): it generates
impressions of the attributes of
objects of perception and thought.
These impressions are not
voluntary and need not be
verbally explicit.
System 2 (Reasoning): it generates
judgments, that are always explicit
and intentional, whether or not
they are overtly expressed.
System 2: Reasoning
System 1: Intuition
Top Down
Bottom Up

What is change
13
System 2: Reasoning
Rules/Beliefs
System 1: Intuition
Emotions/Simulation

What is change
14
The existence of two different cognitive systems is clearly
shown by the dissociation between verbal
knowledge and task performance:
•people learn to control dynamic systems
intuitively without being able to specify the nature of
the relations within the system (e.g. Bicycling), and
•they can describe the rules by which the system
operates without being able to put them into
practice (e.g. Driving Exams).

Learning by doing:
where Intuition and Reasoning meet
15
Learning by doing
The best way to learn how to do
something is trying to do it and reflecting
on the outcome (metacognition)
Engage and Motivate in Active Exploration
(Intuition)
To make individuals active participants by creating
situations that challenge them to solve problems.
Apply Metacognition (Reasoning)
To make individuals active participants by creating
situations that challenge them to solve problems
and apply new knowledge.
To facilitate change we need to
develop experiences able to engage
(intuition) and apply metacognition
to them (reasoning)

Virtual Reality as Positive Technology
Virtual Reality can improve our personal experience

This question is at the heart
of the “positive technology”
approach, which is the
scientific and applied
approach to the use of
technology for improving the
quality of our personal
experience.
WHAT IS RIGHT ABOUT TECHNOLOGY?

The concepts of
Positive Technologies
are rooted in the
research work of
Positive and
Cognitive Psychology

Technology can change personal experience
19
using a goal, rules, and a
feedback system (reasoning)
•The goal provides subjects
with a sense of purpose
focusing attention .
•The rules, push subjects to
see the experience in a
different way.
•The feedback system tells
individuals how close they
are to achieving the goal
By Structuring it By Replacing itBy Augmenting it
to achieve multimodal and
mixed experiences
(intuition/reasoning)
•Technology allows
multisensory experiences in
which content and its
interaction are offered
through more than one of
the senses.
•It is possible to use
technology to overlay virtual
objects onto real scenes
By replacing it with a
synthetic one (intuition)
•Using VR, it is possible to
simulate physical presence
in a synthetic world that
reacts to the action of the
subject as if he/she was
really there.
•It is even possible tp provde
illusion of ownership over a
virtual arm or a virtual body

20 Virtual Reality: the best positive technology
The added value
of Virtual Reality:
the high level of
personal efficacy and
self-reflectiveness
generated by its
sense of presence
and emotional
engagement

21
THE USER IS PRESENT
The virtual reality fully
absorbs the user and
replaces his/her reality
Engagement
and Presence
Social RelationshipsInteraction
THE USER ACTS
The virtual experience is not
passive but active allowing
Learning by Doing
THE USER IS NOT ALONE
The virtual experience is also
a social and collaborative
experience (Avatars)
Virtual Reality as Experiential Technology

22 To Virtual Reality as Experience…
However, VR can also be considered:
An experiential technology: VR allows the
reproduction of situations and contexts in a life-like
setting
=> I’m “present” in the simulation
A cognitive technology: in immersive VR all the
body – including the proprioceptive system - is
involved in the action
=> The experience of the body is modified by
Virtual Reality (Sensory re-integration between the
visual and proprioceptive systems)

VR as Cognitive/Experiential Technology
The Neuroscience of Virtual Reality

24 Virtual Reality as Cognitive Technology
Different visions from cognitive sciences –
Situated Cognition, Embodied Cognition,
Enactive Approach - suggest that:
1.Cognition is no more the simple performance of
formal operations on abstract symbols, but has
instead deep roots in sensorimotor
processing.
2. this is allowed by a common coding – the
motor code – shared by perception, action and
concepts.

This vision is supported by the discovery of Bimodal Neurons:
-Mirror neurons are a specific class of neurons that discharge
during a motor act execution and the observation of a
similar action by others.
-Canonical neurons are a specific class of neurons that discharge
during motor act execution and in response to the
presentation of 3-D objects supporting the same motor act;

How do
these
neurons
work?
Using
Predicitive
Coding

During the enaction of a learned skill a sensory prediction of the
outcome of the action (simulation) is produced along with the actual
motor command.
The results of the comparison (which occurs prereflexively)
between the sensory prediction and the sensory consequences of the act
can then be used to track any possible variation in its course (break).

2) This
simulation is
also used for
concepts:
thinking an apple
produces the
simulation of
an action
related to the
apple in a specific
context of use.

On one side, concepts are embodied simulations of actions
On the other side virtual reality allows embodied simulations of actions.
A first possibility is the use virtual reality for modifying concepts
and/or the emotions related to them through embodied
simulations => behavior and cognitions are tied together

But we can do even more. Recent research suggested that
predictive coding is a key brain process behind different
cognitive processes (from the experience of the body to the self):

…on one side, we are in the
body that, according to
predictive coding, it is the
most likely to be our one.

...on the other side, impairments of the predictive coding may
be behind different pathologies (from autism and schizophrenia to
eating disorders)…

...suggesting the possibility
of using Virtual Reality
for hacking and/or
altering the
predictive coding
mechanisms.
The final outcome will be
”Embodied Medicine”:
the use of VR for altering
the experience of
being in a body with
the goal of improving
health and well-being.

Immersive VR
modifies the neural
areas of pain (measured
using a PET): No effects
with videogame
Why?
Hoffman, H. Scientific American, April 2004

In my view, Virtual Reality hacks the predictive coding system suggesting that
the subject is no more present in his/her body: no body, no pain. It is the
opposite of the phantom limb pain: after amputation the subject experiences pain
in the missing limb, in VR the subject does not experience more pain in the real body.

Virtual Reality in practice
Relevant applications of Embodied Medicine

37 Virtual Reality as Embodied Medicine
A first application of VR as Embodied Medicine:
VR in the treatment of Obesity and Eating Disorders

38 Virtual Reality in Obesity and Eating Disorders
Problem 1:
Effects of Diet and
Exercize are difficult
to maintain
Literature shows that fully 90%–
95% of adult obese patients who
lose weight during dietary and
behavioral treatment will return to
their baseline weight after 5 years;
Ten years after treatment only 34%
of obese children had a decreased
percentage overweight; only 30%
were no longer obese.

Yee N, Bailenson, J.N., Ducheneaut (2009).
The Proteus Effect. Communicatin Research. 36(2):285-312.
Fox, J., Bailenson, J. (2010).
Virtual Self Modeling. Media Psychology.13 (3): 335-339.
Rewarding/Punishing Virtual Avatars
improve motivation
VR allows the creation of ideal self-models that can
motivate individualsto adopt new health practices or
positively modify existing ones
Solution 1: VR improves motivation and compliance

Solution 1: VR improves motivation and compliance
Gorini A, Gaggioli A, Riva G. (2007).
Virtual Worlds, Real Healing. Science. Dec 7;318(5856):1549.
Jin, S-A. (2010).
Does imposing a Goal Always improve Exercise Intentions?.
CyberPsychology, Behavior and Social Networking.13 (3): 335-339.
Virtual Reality allows anonymous group
sessions where individuals put into practice
what they have learned.Exercizing Virtual Avatars improve
motivation

Problem 2: Being
obese can be a
symptom of a more
serious eating problem
Binge Eating Disorder (BED) is reported to
effect roughly 3% of the US population,
leaving many people struggling with obesity
and conventional weight loss methods
unaware that they have an eating disorder
that may not respond without appropriate
treatment.
Binge eating is common both among
people with diagnosed eating disorders and
those who are obese so the difference may
be indistinguishable to the untrained eye.

Solution 2: VR allows to assess ED
Ferrer-Garcia M., Guitierrez-Maldonado (2019)
The validity of virtual environments for eliciting emotional responses in patients with
eating disorders and in controls. Behavior Modification, 33 (6): 830-854
VR is a useful vehicle for eliciting similar
emotional reactions to those one would expect
in real life situations: patients showed higher
levels of anxiety and a more depressed mood
after eating, especially high-calorie food, and
after visiting the swimming pool than in the
neutral room.

A. Gorini, E. Griez, A. Petrova, G.Riva (2010)
Virtual Assessment of the emotional responses produced by exposure to real
food, virtual food and photographs of food in patients affected by eating
disorders. Annals of General Psychiatry, 9:30doi:10.1186/1744-859X-9-30
Food presented in a virtual reality (VR)
environment causes the same
emotional responses as real food in ED
patients: virtual food can be used for
the evaluation and treatment of eating
disorders.
Solution 2: VR allows to assess ED

Problem 3: How can
we improve treatment
of obesity and ED?
Eating disorders and obesity are
usually seen as very different problems
but actually share many similarities. In
fact, eating disorders, obesity, and
other weight-related disorders may
overlap as girls move from one
problem, such as unhealthy dieting, to
another, such as obesity.
In particular, body dissatisfaction and
unhealthy dieting practices are linked
to the development of eating
disorders, obesity, and other
problems.

In 496 adolescent girls who completed a baseline assessment
at age 11-15 years and 4 annual follow-ups. The only
significant predictors of Obesity are:
- Dietary Restraint (p<.001);
- Perceived Parental Obesity (p<.02).
Stice et al, (2005), Psychological and Behavioral
Risk Factors for Obesity Onset in Adolescent
Girls. A Prospective Study, Journal of Consulting
and Clinical Psychology, Vol. 73, No. 2, 195-202.
“...I’m on diet because I don’t
like my body”

The clear link between obesity and
ED is body dissatisfaction,
leading to dietary restraint.
However even if most women do not
like their body, only a minority of
women develop clinically
diagnosable weight disorders. Why?

In short: For an impairment in the predictive coding
ED/OB patients are unable to integrate the real-time
sensory data of their body with the memorized ones
A possible explanation:
a Multisensory Integration Deficit

This Multisensory Integration
Deficit may have different causes:
both environmental (stress) or
organic (altered serotoninergic
activity).
Its outcome it is simple: the subject
is locked to a to a negative
body representation, that
perception is not able to update
even after a demanding diet
and a significant weight loss.

Solution 3:
Integrate VR in
a CBT
treatment
If it is true, we don’t have to work only with
our real body (diet) but also with our
virtual body (predictive coding) to
improve actual treatments.
I’m actually using the Integrated Experiential
Therapy (IET) that integrates CBT with
different virtual reality sessions using three
different strategies to counter the
multisensory integration deficit:
•Cue Exposure;
•Reference Frame Shifting;
•Body Swapping.

• Cue Exposure: We use
VR to reduce eating-
related anxiety during and
after exposure to virtual
food, helping to disrupt the
reconsolidation of adverse,
food-related memories.
• More effective than CBT
in a controlled trial with
bulimic and binge patients

• Reference Frame shifting: The patient re-
experience in VR a negative situation related to
her/his body (e.g. teasing) both in first-person
and in third person (seeing and supporting her
avatar in the scene)
• More effective than CBT at 1Yr follow-up in
two controlled trials with obese and binge patients.
FIRST PERSON (Don’t see my body)
THIRD PERSON (I see my avatar)

• Body Swapping: VR allows the patient to experience a totally different body

• Body Swapping: VR allows the patient to experience a body totally different
from her/his one using a visuo/tactile syncronization.
• A case study with a super-super obesity case (BMI =60) and a study with
anorectic patients provide a preliminary support to this technique.

My future challenge: Sonoception
54
Up to now VR has been used to simulate external reality, that is, to make
people feel ‘real’ what is actually not really there (i.e., environment).
I recently proposed a foundational new approach: Sonoception
(www.sonoception.com) the use of sound and vibration for
simulating/stimulating our internal reality (proprioception,
interoception and vestibular input): to make people feel ‘real’ what they
are not feeling, by hacking directly the predictive coding mechanisms of our inner body
(stomach, heart, ear).

Key Ideas to take home…
56
1) Personal Change requires both
Intuition and Reasoning. Learning
by Doing and Metacognition
connect/active both of them.
2) Virtual Reality is able to improve
personal experience by structuring,
augmenting and replacing it.
3) VR as a simulative technology is
based on the same predictive
approach (Predictive Coding) used by
our brain. So, we can use VR for
hacking and/or altering the predictive
coding mechanisms
4) This possibility may open a new
scientific paradigm, ”Embodied
Medicine”: the use of VR for
altering the experience of being in
a body with the goal of improving
health and well-being.

Four Free Books for you…
57
Interacting with Presence
HCI and the Sense of Presence in
Computer-mediated Environments
http://www.degruyter.com/view/product/449569
Volutaren plus isa
Thank you for your attention
Enabling Positive Change
Flow and Complexity in Daily Experience
http://www.degruyter.com/view/product/449663
Active Ageing and Healthy Living: A Human
Centered Approach in Research and
Innovation as Source of Quality of Life
http://www.activeaging.it/
Human Computer Confluence
Transforming Human Experience through
Symbiotic Technologies
https://www.degruyter.com/view/product/469548
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