Augmenting Group Medical Visits with Conversational Agents for Stress Management Behavior Change

  • Ameneh ShamekhiEmail author
  • Timothy Bickmore
  • Anna Lestoquoy
  • Paula Gardiner
Conference paper
Part of the Lecture Notes in Computer Science book series (LNCS, volume 10171)


Individuals with chronic stress can improve their overall wellness by making lifestyle changes. We describe the design and evaluation of a computer-animated conversational agent that is used in conjunction with Integrative Medical Group Visits (IMGV) to help individuals with chronic pain and depression manage their stress. The agent coaches patients in between group visit sessions, reviewing how to manage stress using non-pharmaceutical techniques (e.g., mindfulness, meditation, yoga self-massage). We conducted a longitudinal clinical trial with 154 participants in which patients in the intervention group interacted with the conversational agent at home on a touch screen tablet to reinforce what they learned in group medical visits. Results from the trial indicate that the conversational agent, in conjunction with medical group visits, leads to significantly more positive stress management behaviors in patients compared to outcomes that arise in usual care, after 9 and 21 weeks.


Conversational agent Health behavior change Meditation Stress management Complementary and alternative medicine 



Research reported in this paper was partially funded through a Patient-Centered Outcomes Research Institute (PCORI) Award (AD-1304-6218).


  1. 1.
    Brennan, J., Hwang, D., Phelps, K.: Group visits and chronic disease management in adults: a review. Am. J. Lifestyle Med. 5, 69–84 (2011)CrossRefGoogle Scholar
  2. 2.
    Jaber, R., Braksmajer, A., Trilling, J.S.: Group visits: a qualitative review of current research. J. Am. Board Fam. Med. 19, 276–290 (2006)CrossRefGoogle Scholar
  3. 3.
    Trotter, K.J.: The promise of group medical visits. Nurse Pract. 38, 48–53 (2013)CrossRefGoogle Scholar
  4. 4.
    Chiesa, A., Serretti, A.: Mindfulness-based stress reduction for stress management in healthy people: a review and meta-analysis. J. Altern. Complement. Med. 15, 593–600 (2009)CrossRefGoogle Scholar
  5. 5.
    Gardiner, P., Dresner, D., Barnett, K.G., Sadikova, E., Saper, R.: Medical group visits: a feasibility study to manage patients with chronic pain in an underserved urban clinic. Glob. Adv. Health Med. 3, 20–26 (2014)CrossRefGoogle Scholar
  6. 6.
    Newman, M.G., Szkodny, L.E., Llera, S.J., Przeworski, A.: A review of technology-assisted self-help and minimal contact therapies for anxiety and depression: is human contact necessary for therapeutic efficacy? Clin. Psychol. Rev. 31, 89–103 (2011)CrossRefGoogle Scholar
  7. 7.
    Gaggioli, A., Cipresso, P., Serino, S., Campanaro, D.M., Pallavicini, F., Wiederhold, B.K., Riva, G.: Positive technology: a free mobile platform for the self-management of psychological stress. Stud. Health Tech. Inform. 199, 25–29 (2014)Google Scholar
  8. 8.
    Al Osman, H., Dong, H., El Saddik, A.: Ubiquitous biofeedback serious game for stress management. IEEE Access. 4, 1274–1286 (2016)CrossRefGoogle Scholar
  9. 9.
    Gromala, D., Tong, X., Choo, A., Karamnejad, M., Shaw, C.D.: The virtual meditative walk: virtual reality therapy for chronic pain management. In: Proceedings of the 33rd Annual ACM Conference on Human Factors in Computing Systems, pp. 521–524. ACM (2015)Google Scholar
  10. 10.
    Kosunen, I., Salminen, M., Järvelä, S., Ruonala, A., Ravaja, N., Jacucci, G.: RelaWorld: neuroadaptive and immersive virtual reality meditation system. In: Presented at the 21st International Conference on Intelligent User Interfaces. ACM (2016)Google Scholar
  11. 11.
    Bickmore, T., Giorgino, T.: Health dialog systems for patients and consumers. J. Biomed. Inform. 39, 556–571 (2006)CrossRefGoogle Scholar
  12. 12.
    Bickmore, T.W., Silliman, R.A., Nelson, K., Cheng, D.M., Winter, M., Henault, L., Paasche-Orlow, M.K.: A randomized controlled trial of an automated exercise coach for older adults. J. Am. Geriatr. Soc. 61, 1676–1683 (2013)CrossRefGoogle Scholar
  13. 13.
    Watson, A., Bickmore, T., Cange, A., Kulshreshtha, A., Kvedar, J.: An internet-based virtual coach to promote physical activity adherence in overweight adults: randomized controlled trial. J. Med. Internet Res. 14, e1 (2012)CrossRefGoogle Scholar
  14. 14.
    Edwards, R.A., Bickmore, T., Jenkins, L., Foley, M., Manjourides, J.: Use of an interactive computer agent to support breastfeeding. Matern. Child Health J. 17, 1961–1968 (2013)CrossRefGoogle Scholar
  15. 15.
    Horsch, C., Brinkman, W.-P., van Eijk, R., Neerincx, M.A.: Towards the usage of persuasive strategies in a virtual sleep coach. In: Proceedings of UKHCI 2012 Workshop on People, Computers and Psychotherapy (2012)Google Scholar
  16. 16.
    Bickmore, T., Gruber, A., Picard, R.: Establishing the computer–patient working alliance in automated health behavior change interventions. Patient Educ. Couns. 59, 21–30 (2005)CrossRefGoogle Scholar
  17. 17.
    Schulman, D., Bickmore, T.: Persuading users through counseling dialogue with a conversational agent. In: Proceedings of the 4th International Conference on Persuasive Technology, pp. 25. ACM (2009)Google Scholar
  18. 18.
    Bickmore, T., Schulman, D.: An Intelligent Conversational Agent for Promoting Long-Term Health Behavior Change Using Motivational Interviewing. In: AAAI Spring Symposium: AI and Health Communication (2011)Google Scholar
  19. 19.
    Monkaresi, H., Calvo, R., Pardo, A., Chow, K., Mullan, B., Lam, M., Twigg, S.M., Cook, D.I.: Intelligent diabetes lifestyle coach. In: OzCHI, Adelaide, Australia (2013)Google Scholar
  20. 20.
    Bickmore, T., Puskar, K., Schlenk, E., Pfeifer, L., Sereika, S.: Maintaining reality: relational agents for antipsychotic medication adherence. Interact. Comput. 22, 276–288 (2010)CrossRefGoogle Scholar
  21. 21.
    Meeker, D.: SimCoach evaluation: a virtual human intervention to encourage service-member help-seeking for posttraumatic stress disorder and depression. Rand Corporation, Santa Monica (2015)Google Scholar
  22. 22.
    Hudlicka, E.: Virtual training and coaching of health behavior: example from mindfulness meditation training. Patient Educ. Couns. 92, 160–166 (2013)CrossRefGoogle Scholar
  23. 23.
    Shamekhi, A., Bickmore, T.: Breathe with me: a virtual meditation coach. In: Brinkman, W.-P., Broekens, J., Heylen, D. (eds.) Intelligent Virtual Agents, pp. 279–282. Springer International Publishing, Cham (2015)CrossRefGoogle Scholar
  24. 24.
    Jin, S.-A.A.: The effects of incorporating a virtual agent in a computer-aided test designed for stress management education: the mediating role of enjoyment. Comput. Hum. Behav. 26, 443–451 (2010)CrossRefGoogle Scholar
  25. 25.
    Shamekhi, A., Bickmore, T., Lestoquoy, A., Negash, L., Gardiner, P.: Blissful agents: adjuncts to group medical visits for chronic pain and depression. In: Traum, D., Swartout, W., Khooshabeh, P., Kopp, S., Scherer, S., Leuski, A. (eds.) IVA 2016. LNCS (LNAI), vol. 10011, pp. 433–437. Springer, Heidelberg (2016). doi: 10.1007/978-3-319-47665-0_49 CrossRefGoogle Scholar
  26. 26.
    Cassell, J., Vilhjálmsson, H.H., Bickmore, T.: BEAT: the Behavior Expression Animation Toolkit. In: Prendinger, H., Ishizuka, M. (eds.) Life-Like Characters, pp. 163–185. Springer, Heidelberg (2004)CrossRefGoogle Scholar
  27. 27.
    Bickmore, T.W., Picard, R.W.: Establishing and maintaining long-term human-computer relationships. ACM Trans. Comput. Hum. Interact. 12, 293–327 (2005)Google Scholar
  28. 28.
    Kabat-Zinn, J.: Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. Bantam Books trade paperback, New York (2013)Google Scholar
  29. 29.
    Sharma, M., Rush, S.E.: Mindfulness-based stress reduction as a stress management intervention for healthy individuals: a systematic review. J. Evid. Based Complement. Altern. Med. 19, 271–286 (2014)Google Scholar
  30. 30.
    Hofmann, S.G., Sawyer, A.T., Witt, A.A., Oh, D.: The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. J. Consult. Clin. Psychol. 78, 169–183 (2010)CrossRefGoogle Scholar
  31. 31.
    Bickmore, T.W., Pfeifer, L.M., Byron, D., Forsythe, S., Henault, L.E., Jack, B.W., Silliman, R., Paasche-Orlow, M.K.: Usability of conversational agents by patients with inadequate health literacy: evidence from two clinical trials. J. Health Commun. 15, 197–210 (2010)CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Ameneh Shamekhi
    • 1
    Email author
  • Timothy Bickmore
    • 1
  • Anna Lestoquoy
    • 2
  • Paula Gardiner
    • 2
  1. 1.College of Computer and Information ScienceNortheastern UniversityBostonUSA
  2. 2.Department of Family MedicineBoston Medical CenterBostonUSA

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