Design and Evaluation of Personalized Motivational Messages by a Virtual Agent that Assists in Post-Traumatic Stress Disorder Therapy.

BACKGROUND: Systems incorporating virtual agents can play a major role in electronic-mental (e-mental) health care, as barriers to care still prevent some patients from receiving the help they need. To properly assist the users of these systems, a virtual agent needs to promote motivation. This can be done by offering motivational messages. OBJECTIVE: The objective of this study was two-fold. The first was to build a motivational message system for a virtual agent assisting in post-traumatic stress disorder (PTSD) therapy based on domain knowledge from experts. The second was to test the hypotheses that (1) computer-generated motivating messages influence users' motivation to continue with therapy, trust in a good therapy outcome, and the feeling of being heard by the agent and (2) personalized messages outperform generic messages on these factors. METHODS: A system capable of generating motivational messages was built by analyzing expert (N=13) knowledge on what types of motivational statements to use in what situation. To test the 2 hypotheses, a Web-based study was performed (N=207). Participants were asked to imagine they were in a certain situation, specified by the progression of their symptoms and initial trust in a good therapy outcome. After this, they received a message from a virtual agent containing either personalized motivation as generated by the system, general motivation, or no motivational content. They were asked how this message changed their motivation to continue and trust in a good outcome as well as how much they felt they were being heard by the agent. RESULTS: Overall, findings confirmed the first hypothesis, as well as the second hypothesis for the measure feeling of being heard by the agent. Personalization of the messages was also shown to be important in those situations where the symptoms were getting worse. In these situations, personalized messages outperformed general messages both in terms of motivation to continue and trust in a good therapy outcome. CONCLUSIONS: Expert input can successfully be used to develop a personalized motivational message system. Messages generated by such a system seem to improve people's motivation and trust in PTSD therapy as well as the user's feeling of being heard by a virtual agent. Given the importance of motivation, trust, and therapeutic alliance for successful therapy, we anticipate that the proposed system can improve adherence in e-mental therapy for PTSD and that it can provide a blueprint for the development of an adaptive system for persuasive messages based on expert input.

Considering patient safety in autonomous e-mental health systems - detecting risk situations and referring patients back to human care.

BACKGROUND: Digital health interventions can fill gaps in mental healthcare provision. However, autonomous e-mental health (AEMH) systems also present challenges for effective risk management. To balance autonomy and safety, AEMH systems need to detect risk situations and act on these appropriately. One option is sending automatic alerts to carers, but such 'auto-referral' could lead to missed cases or false alerts. Requiring users to actively self-refer offers an alternative, but this can also be risky as it relies on their motivation to do so. This study set out with two objectives. Firstly, to develop guidelines for risk detection and auto-referral systems. Secondly, to understand how persuasive techniques, mediated by a virtual agent, can facilitate self-referral. METHODS: In a formative phase, interviews with experts, alongside a literature review, were used to develop a risk detection protocol. Two referral protocols were developed - one involving auto-referral, the other motivating users to self-refer. This latter was tested via crowd-sourcing (n = 160). Participants were asked to imagine they had sleeping problems with differing severity and user stance on seeking help. They then chatted with a virtual agent, who either directly facilitated referral, tried to persuade the user, or accepted that they did not want help. After the conversation, participants rated their intention to self-refer, to chat with the agent again, and their feeling of being heard by the agent. RESULTS: Whether the virtual agent facilitated, persuaded or accepted, influenced all of these measures. Users who were initially negative or doubtful about self-referral could be persuaded. For users who were initially positive about seeking human care, this persuasion did not affect their intentions, indicating that a simply facilitating referral without persuasion was sufficient. CONCLUSION: This paper presents a protocol that elucidates the steps and decisions involved in risk detection, something that is relevant for all types of AEMH systems. In the case of self-referral, our study shows that a virtual agent can increase users' intention to self-refer. Moreover, the strategy of the agent influenced the intentions of the user afterwards. This highlights the importance of a personalised approach to promote the user's access to appropriate care.

A Therapy System for Post-Traumatic Stress Disorder Using a Virtual Agent and Virtual Storytelling to Reconstruct Traumatic Memories.

Although post-traumatic stress disorder (PTSD) is well treatable, many people do not get the desired treatment due to barriers to care (such as stigma and cost). This paper presents a system that bridges this gap by enabling patients to follow therapy at home. A therapist is only involved remotely, to monitor progress and serve as a safety net. With this system, patients can recollect their memories in a digital diary and recreate them in a 3D WorldBuilder. Throughout the therapy, a virtual agent is present to inform and guide patients through the sessions, employing an ontology-based question module for recollecting traumatic memories to further elicit a detailed memory recollection. In a usability study with former PTSD patients (n = 4), these questions were found useful for memory recollection. Moreover, the usability of the whole system was rated positively. This system has the potential to be a valuable addition to the spectrum of PTSD treatments, offering a novel type of home therapy assisted by a virtual agent.

Meaningful human control and variable autonomy in human-robot teams for firefighting.

Introduction: Humans and robots are increasingly collaborating on complex tasks such as firefighting. As robots are becoming more autonomous, collaboration in human-robot teams should be combined with meaningful human control. Variable autonomy approaches can ensure meaningful human control over robots by satisfying accountability, responsibility, and transparency. To verify whether variable autonomy approaches truly ensure meaningful human control, the concept should be operationalized to allow its measurement. So far, designers of variable autonomy approaches lack metrics to systematically address meaningful human control. Methods: Therefore, this qualitative focus group (n = 5 experts) explored quantitative operationalizations of meaningful human control during dynamic task allocation using variable autonomy in human-robot teams for firefighting. This variable autonomy approach requires dynamic allocation of moral decisions to humans and non-moral decisions to robots, using robot identification of moral sensitivity. We analyzed the data of the focus group using reflexive thematic analysis. Results: Results highlight the usefulness of quantifying the traceability requirement of meaningful human control, and how situation awareness and performance can be used to objectively measure aspects of the traceability requirement. Moreover, results emphasize that team and robot outcomes can be used to verify meaningful human control but that identifying reasons underlying these outcomes determines the level of meaningful human control. Discussion: Based on our results, we propose an evaluation method that can verify if dynamic task allocation using variable autonomy in human-robot teams for firefighting ensures meaningful human control over the robot. This method involves subjectively and objectively quantifying traceability using human responses during and after simulations of the collaboration. In addition, the method involves semi-structured interviews after the simulation to identify reasons underlying outcomes and suggestions to improve the variable autonomy approach.

Exploring the effect of automation failure on the human's trustworthiness in human-agent teamwork.

Introduction: Collaboration in teams composed of both humans and automation has an interdependent nature, which demands calibrated trust among all the team members. For building suitable autonomous teammates, we need to study how trust and trustworthiness function in such teams. In particular, automation occasionally fails to do its job, which leads to a decrease in a human's trust. Research has found interesting effects of such a reduction of trust on the human's trustworthiness, i.e., human characteristics that make them more or less reliable. This paper investigates how automation failure in a human-automation collaborative scenario affects the human's trust in the automation, as well as a human's trustworthiness towards the automation. Methods: We present a 2 × 2 mixed design experiment in which the participants perform a simulated task in a 2D grid-world, collaborating with an automation in a "moving-out" scenario. During the experiment, we measure the participants' trustworthiness, trust, and liking regarding the automation, both subjectively and objectively. Results: Our results show that automation failure negatively affects the human's trustworthiness, as well as their trust in and liking of the automation. Discussion: Learning the effects of automation failure in trust and trustworthiness can contribute to a better understanding of the nature and dynamics of trust in these teams and improving human-automation teamwork.

The influence of interdependence and a transparent or explainable communication style on human-robot teamwork.

Humans and robots are increasingly working together in human-robot teams. Teamwork requires communication, especially when interdependence between team members is high. In previous work, we identified a conceptual difference between sharing what you are doing (i.e., being transparent) and why you are doing it (i.e., being explainable). Although the second might sound better, it is important to avoid information overload. Therefore, an online experiment (n = 72) was conducted to study the effect of communication style of a robot (silent, transparent, explainable, or adaptive based on time pressure and relevancy) on human-robot teamwork. We examined the effects of these communication styles on trust in the robot, workload during the task, situation awareness, reliance on the robot, human contribution during the task, human communication frequency, and team performance. Moreover, we included two levels of interdependence between human and robot (high vs. low), since mutual dependency might influence which communication style is best. Participants collaborated with a virtual robot during two simulated search and rescue tasks varying in their level of interdependence. Results confirm that in general robot communication results in more trust in and understanding of the robot, while showing no evidence of a higher workload when the robot communicates or adds explanations to being transparent. Providing explanations, however, did result in more reliance on RescueBot. Furthermore, compared to being silent, only being explainable results a higher situation awareness when interdependence is high. Results further show that being highly interdependent decreases trust, reliance, and team performance while increasing workload and situation awareness. High interdependence also increases human communication if the robot is not silent, human rescue contribution if the robot does not provide explanations, and the strength of the positive association between situation awareness and team performance. From these results, we can conclude that robot communication is crucial for human-robot teamwork, and that important differences exist between being transparent, explainable, or adaptive. Our findings also highlight the fundamental importance of interdependence in studies on explainability in robots.

A randomized controlled trial to pilot the efficacy of a computer-based intervention with elements of virtual reality and limited therapist assistance for the treatment of post-traumatic stress disorder.

Although well-established therapies exist for post-traumatic stress disorder (PTSD), barriers to seek mental health care are high. Technology-based interventions may play a role in improving the reach of efforts to treat, especially when therapist availability is low. The goal of the current randomized controlled trial was to pilot the efficacy of a computer-based trauma intervention with elements of virtual reality (VR; 3MR system) and limited therapist involvement for the treatment of PTSD in a childhood sexual abuse (CSA) and war veteran sample and to compare this to "treatment as usual" (TAU). TAU consisted of evidence-based approaches such as imaginal exposure, EMDR, or narrative exposure therapy. A total of 44 patients with PTSD were included and randomly assigned to 12 sessions of 3MR intervention or TAU (completer n 3MR = 12, TAU = 18). Several measures (PCL-5, BDI-II, OQ-45-2, and the M.I.N.I. 5.0.0.) were administered to measure symptoms of PTSD and depression and scores of overall well-being at pre, post, and a three-month follow-up measurement. Analyses suggest that symptoms of PTSD and depression in the 3MR condition decreased, and overall well-being increased between pre and post measurements. Results did not indicate any clear differences between the treatment conditions over time which suggests that treatment gains of the 3MR intervention seem no less than those of TAU. Finally, both treatment conditions produced similar remission rates of PTSD and depression. Therefore, the 3MR intervention could possibly constitute an appropriate treatment alternative. The small sample size as well as evident drop-out rates in the 3MR condition (45%) do warrant further research. The procedures of this study were approved by the Medical Ethical Research Committee (MERC) of the Erasmus Medical Center in Rotterdam (MEC-NL46279.078.13) and pre-registered via ClinicalTrials.gov (Protocol Record CI1-12-S028-1).

How should a virtual agent present psychoeducation? Influence of verbal and textual presentation on adherence.

BACKGROUND AND OBJECTIVE: With the rise of autonomous e-mental health applications, virtual agents can play a major role in improving trustworthiness, therapy outcome and adherence. In these applications, it is important that patients adhere in the sense that they perform the tasks, but also that they adhere to the specific recommendations on how to do them well. One important construct in improving adherence is psychoeducation, information on the why and how of therapeutic interventions. In an e-mental health context, this can be delivered in two different ways: verbally by a (virtual) embodied conversational agent or just via text on the screen. The aim of this research is to study which presentation mode is preferable for improving adherence. METHODS: This study takes the approach of evaluating a specific part of a therapy, namely psychoeducation. This was done in a non-clinical sample, to first test the general constructs of the human-computer interaction. We performed an experimental study on the effect of presentation mode of psychoeducation on adherence. In this study, we took into account the moderating effects of attitude towards the virtual agent and recollection of the information. Within the paradigm of expressive writing, we asked participants (n= 46) to pick one of their worst memories to describe in a digital diary after receiving verbal or textual psychoeducation. RESULTS AND CONCLUSION: We found that both the attitude towards the virtual agent and how well the psychoeducation was recollected were positively related to adherence in the form of task execution. Moreover, after controlling for the attitude to the agent and recollection, presentation of psychoeducation via text resulted in higher adherence than verbal presentation by the virtual agent did.