VideoTherapy (VDT) as a therapeutic tool. Pilot study on a new treatment protocol
During adolescence, every experience and relationship contributes to develop one’s identity and early psychotic experiences influence the ability of individuals to integrate their personality into a unified and coherent structure.
Antonio Cozzi – OPEN SCHOOL, Cognitive Psychotherapy and Research Milan
VideoTherapy (VDT) is an intervention protocol based on the use of videoconference techniques. It was conceived, developed and studied at the Centro Adolescenza in Bassano del Grappa (VI) as a response to the need to implement innovative and specific treatment methods, to be combined with standard techniques, with the aim of strengthening some aspects of perception of Self and self-awareness (Brazzale et al., 2018).
The Centro Adolescenza is an early intervention and prevention service for young people with psychological distress, first manifestations of mental disorders, mental states at risk or psychotic onset. The experience gained in this area has meant that the need to reinforce some aspects of self-perception and the world that appear dysfunctional in young people, in particular in those at risk, emerged.
A first reflection is linked to the fact that psychotic experiences – especially early ones – carry with them the risk of affecting the perception of a coherent, unique and solid Self, leading to the fragmentation of the Self (Goldstein, 1995; Cullberg, 2006).
Therefore, considering the youth population, it is understandable how these reflections take on importance. During adolescence, in fact, every experience and relationship contributes to develop one’s identity and early psychotic experiences influence the ability of individuals to integrate their personality into a unified and coherent structure. The first psychotic episode in this sense can have dramatic consequences, giving rise to feelings of bewilderment, discontinuity, diminished internal consistency and confusion (Grazebrook et al., 2004; Cullberg, 2006; Hertz, 2008).
In addition to self-perception, there is another component frequently damaged in these disorders: the perception of the other, of the external world, which has consequences on relationships and on the quality of social interactions (Flaherty, 2014). Studies on Metacognition, in particular by Stephen Moritz, have confirmed that there are specific biases active in these contexts of interaction, leading the author to develop a specific Training for psychosis based on strengthening specific skills and making certain strategies more flexible cognitive actions in social situations, such as jumping to conclusions and attributive styles (Moritz et al. 2010: Moritz et al. 2013; Moritz et al. 2016).
On the basis of these studies, it was decided to evaluate the possibility of introducing VDT as a new and innovative tool for strengthening self-perception, accompanied by an already standardized tool that had as its focus the perception of the outside, through the use of Metacognitive Training for Psychoses (Moritz et al., 2013). Well before the clinical and therapeutic efficacy of this tool, it was important to evaluate its sustainability within a public service, observing and considering the feedback of the young participants in this first phase.
VDT is a tool that is based on the encounter and comparison between the individual and his own image, with which he dialogues and reflects, studied in various application forms with patients with Eating Disorders, Mood Disorders and Schizophrenia (Brazzale et al., 2018). Giusti (1999) underlines how this meeting founds the basis for a review experience: through interaction with the reflected image, the same image becomes the subject’s interlocutor in a process of confrontation with themselves.
The purpose of this operation is to make the subject’s interpretative methods more adaptive and healthy, leading him to consider reality no longer as objective, but as the result of an active operation by the perceiving subject. One of the main therapeutic effects of VDT comes into play when the image becomes autonomous, or rather, when a process of “distancing” from the mental image of oneself occurs. The playback phase in the VDT protocol has precisely this fundamental function within the change process.
This distance between the reflected image and the mental image also allows the individual to recognize the discrepancies between the ideal self and the real self, setting in motion a necessary process of differentiation and / or integration of the different aspects of the self represented and thought. , as well as deepen the awareness of some relational and interaction modalities.
We believed that this project of using the VDT techniques could promote a new perception and psychological experience, unusual and original, whose aim could be the integration of the different parts of the self neutralizing the psychotic dissociation. Further therapeutic effects of VDT, moreover, appear to be active in the ability to stimulate an observation and monitoring of their own biases implicated Self judgment (Internal bias, judgment and monitoring of the Self) (Brazzale et al. 2018). This action could therefore act on the social Self or narrative Self, one of the most advanced structures of the Self, which allows the individual to access a reflection on himself to describe himself. This structure is among the first to be compromised in the risk phases,
In 2015, therefore, a pilot study was conducted by various Local Health Authorities of the Veneto region, in order to test the applicability of the instrument within the public health system and observe its possible clinical efficacy. Considering that the main objective was to evaluate the sustainability of the intervention, qualitative observations were mainly carried out, accompanied by the pre- and post-intervention administration, of some clinical tests and questionnaires to evaluate symptomatic areas, the theory of mind and skills perceptual and visual image manipulation. As mentioned above, the clinical efficacy of the technique was not investigated in this first phase, which is why data analysis had a more marginal role, albeit giving encouraging indications regarding a possible efficacy. These data were however exposed and discussed in the original manuscript published at American Psychiatry (Brazzale et al, 2018).
In this experimental phase, the VDT protocol was tested with boys who reported a mild psychotic symptomatology, rather than with those who had already experienced a psychotic episode (FEP), in order to assess the viability with the population in the premorbid phase and therefore at clinical risk (CHR) based on clinical and research data according to which the same pseudo-psychotic experiences are present in these phases already in a mild form (Larson et al, 2010; Yung et al, 2013, Cozzi, 2017).
The VDT takes place through the use of an I-Pad or tablet placed at eye level, with which the subject interacts in various forms. The main techniques consist of Video Comparison, Video Story and PlayBack (Brazzale et al., 2018).
In the Video Comparison, individuals are observed in the monitor, commenting on the image, feelings and sensations elicited, dialoguing with the person reflected on the screen.
In the Video Story the subject works with photos of himself that he brings to the session, describing the circumstances, feelings, emotions and memories that they aroused in him.
The PlayBack is a moment when the subject reviews the session recorded via the tablet and is stimulated to make further comments and tell their feelings in seeing each other.
This protocol was applied to 18 adolescents (12-21 years), in charge at the local ULSS and assessed as at risk for the development of a psychotic disorder, with the aim of evaluating its applicability in an outpatient setting. The experimental nature of the intervention was explained to the boys, which did not replace the standard treatment they were carrying out.
The results and the positive response of the young people treated allowed to verify the application sustainability of the intervention. VDT appeared as a promising technique, in fact it was an original, interesting and attractive activity for the kids.
The interest shown by young people in relation to these new alternative techniques to the standard interview has also made it possible to contrast isolation and resistance in therapy, effectively stimulating in boys a renewed curiosity and active participation in the therapeutic process.
Observations were made regarding possible short-term clinical efficacy, which showed that there are indeed encouraging data. However, the limitations related to the low number and representativeness of the sample do not allow more conclusions to be drawn.
Finally, the association of VDT with meta-cognitive intervention techniques gave complementarity and incisiveness to the intervention (Brazzale et al., 2018).