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Virtual reality therapy (VRT), also known as virtual reality immersion therapy (VRIT), simulation for therapy (SFT), virtual reality exposure therapy (VRET), and computerized CBT (CCBT), is the use of virtual reality technology for psychological or occupational therapy. Patients receiving virtual reality therapy navigate through digitally created environments and complete specially designed tasks often tailored to treat a specific ailment. Technology can range from a simple PC and keyboard setup, to a modern virtual reality headset. It is widely used as an alternative form of exposure therapy, in which patients interact with harmless virtual representations of traumatic stimuli in order to reduce fear responses. It has proven to be especially effective at treating PTSD. Virtual reality therapy has also been used to help stroke patients regain muscle control, to treat other disorders such as body dysmorphia, and to improve social skills in those diagnosed with autism.

Description[edit]

Virtual reality therapy (VRT) uses specially programmed computers, visual immersion devices and artificially created environments to give the patient a simulated experience[1] that can be used to diagnose and treat psychological conditions that cause difficulties for patients. In many environmental phobias, reaction to the perceived hazards, such as heights, speaking in public, flying, close spaces, are usually triggered by visual and auditory stimuli. In VR-based therapies, the virtual world is a means of providing artificial, controlled stimuli in the context of treatment, and with a therapist able to monitor the patient's reaction. Unlike traditional cognitive behavior therapy, VR-based treatment may involve adjusting the virtual environment, such as for example adding controlled intensity smells or adding and adjusting vibrations, and allow the clinician to determine the triggers and triggering levels for each patient's reaction. VR-based therapy systems may allow replaying virtual scenes, with or without adjustment, to habituate the patient to such environments. Therapists who apply virtual reality exposure therapy, just as those who apply in-vivo exposure therapy, can take one of two approaches concerning the intensity of exposure. The first approach is called flooding, which refers to the most intense approach where stimuli that produce the most anxiety are presented first. For soldiers who have developed PTSD from combat, this could mean first exposing them to a virtual reality scene of their fellow troops being shot or injured followed by less stressful stimuli such as only the sounds of war. On the other hand, what is referred to as graded-exposure takes a more relaxed approach in which the least distressing stimuli are introduced first.[2] VR-exposure, as compared to in-vivo exposure has the advantage of providing the patient a vivid experience, without the associated risks or costs. VRT has great promise since it historically produces a "cure" about 90% of the time at about half the cost of traditional cognitive behavior therapy authority, and is especially promising as a treatment for PTSD[3][4] where there are simply not enough psychologists and psychiatrists to treat all the veterans with anxiety disorders diagnosed as related to their military service.[5][6][7]

Recently there have been some advances in the field of virtual reality medicine. Virtual reality is a complete immersion of the patient into a virtual world by putting on a headset with an LED screen in the lenses of the headset. This is different from the recent advancements in augmented reality. Augmented reality is different in the sense that it enhances the non-synthetic environment by introducing synthetic elements to the user's perception of the world.[8] This in turn "augments" the current reality and uses virtual elements to build upon the existing environment.[8] Augmented reality poses additional benefits and has proven itself to be a medium through which individuals suffering from specific phobia can be exposed "safely" to the object(s) of their fear, without the costs associated with programming complete virtual environments. Thus, augmented reality can offer an efficacious alternative to some less advantageous exposure-based therapies.[8]

History[edit]

Virtual reality therapy (VRT) was pioneered and originally termed by Max North documented by the first known publication (Virtual Environment and Psychological Disorders, Max M. North, and Sarah M. North, Electronic Journal of Virtual Culture, 2,4, July 1994), his doctoral VRT dissertation completion in 1995 (began in 1992), and followed with the first known published VRT book in 1996 (Virtual Reality Therapy, an Innovative Paradigm, Max M. North, Sarah M. North, and Joseph R. Coble, 1996. IPI Press. ISBN 1-880930-08-0). His pioneered virtual reality technology work began as early as 1992 as a research faculty at Clark Atlanta University and supported by funding from U.S. Army Research Laboratory.

An early exploration in 1993–1994 of VRT[9][self-published source?] was done by Ralph Lamson[10] a USC graduate then at Kaiser Permanente Psychiatry Group. Lamson began publishing his work in 1993.[11][12][medical citation needed] As a psychologist, he was most concerned with the medical and therapeutic aspects, that is, how to treat people using the technology, rather than the apparatus, which was obtained from Division, Inc. Psychology Today reported in 1994 that these 1993–1994 treatments were successful in about 90%[11][medical citation needed] of Lamson's virtual psychotherapy patients. Lamson wrote in 1993 a book entitled Virtual Therapy which was published in 1997 directed primarily to the detailed explanation of the anatomical, medical and therapeutic basis for the success of VRT.[13] In 1994–1995, he had solved his own acrophobia in a test use of a third party VR simulation and then set up a 40 patient test funded by Kaiser Permanente.[9][third-party source needed] Shortly thereafter, in 1994–1995, Larry Hodges, then a computer scientist at Georgia Tech active in VR, began studying VRT in cooperation with Max North who had reported anomalous behavior in flying carpet simulation VR studies and attributed such to phobic response of unknown nature. Hodges tried to hire Lamson without success in 1994 and instead began working with Barbara Rothbaum, a psychologist at Emory University to test VRT in controlled group tests, experiencing about 70% success among 50% of subjects completing the testing program.[citation needed]

In 2005, Skip Rizzo of USC's Institute for Creative Technologies, with research funding from the Office of Naval Research (ONR),[14] started validating a tool he created using assets from the game Full Spectrum Warrior for the treatment of posttraumatic stress disorder. Virtual Iraq was subsequently evaluated and improved under ONR funding and is supported by Virtually Better, Inc. They also support applications of VR-based therapy for aerophobia, acrophobia, glossophobia, and substance abuse. Virtual Iraq proved successful in normalization of over 70% of PTSD sufferers, and that has now become a standard accepted treatment by the Anxiety and Depression Association of America. However, the VA has continued to emphasize traditional prolonged exposure therapy as the treatment of choice, and VR-based therapies have gained only limited adoption, despite active promotion by DOD. This is interesting[according to whom?] in view of VRT having much lower cost and apparently higher success rates, and a $12-million ONR funded study is currently underway to definitively compare the efficacy of the two methods, PET and VRT. Military labs have subsequently set up dozens of VRT labs and treatment centers for treating both PTSD and a variety of other medical conditions. The use of VRT has thus become a mainstream psychiatric treatment for anxiety disorders and is finding increasing use in the treatment of other cognitive disorders associated with various medical conditions such as addiction, depression and insomnia.[12]

Applications[edit]

Psychological therapy[edit]

Exposure therapy[edit]

Virtual reality technology is especially useful for exposure therapy – a treatment method in which patients are introduced and then slowly exposed to a traumatic stimulus. Inside virtual environments, patients can safely interact with a representation of their phobia, and researchers don't need to have access to a real version of the phobia itself.

One very successful example of virtual reality therapy exposure therapy is the PTSD treatment system, Virtual Iraq. Using a head mounted display and a game pad, patients navigate a Humvee around virtual recreations of Iraq, Afghanistan, and the United States. By being safely exposed to the traumatic environments, patients learned to reduce their anxiety. According to a review of the history of Virtual Iraq, one study found that it reduced PTSD symptoms by an average of fifty percent, and disqualified over seventy-five percent of participants for PTSD after treatment.[15] Virtual reality exposure therapy is also commonly used for treating specific phobias, especially small animal phobia. Commonly feared animals such as spiders can be easily produced in a virtual environment, rather than requiring the therapist or researcher to go find the real-life counterpart.[16] This technique has also been used experimentally to treat other fears such as public speaking and claustrophobia.[16][17]

In 2011, three researchers at York University proposed an affordable virtual reality exposure therapy (VRET) system for the treatment of phobias that could be set up at home.[18]

BRAVEMIND[edit]

In 2014, a virtual reality application used as a prolonged exposure (PE) therapy tool for military related trauma called BRAVEMIND was reported[19] BRAVEMIND is as an acronym for Battlefield Research Accelerating Virtual Environments for Military Individual Neuro Disorders.[20] Virtual reality exposure therapy (VRET) applications have been used to assist civilian populations with anxieties about flying, public speaking, and heights. BRAVEMIND has been studied in populations of military medics as well as survivors of military sexual assault and combat.[19][21][22] This techonology was developed by researchers at the University of the Southern California in collaboration with the U.S. Army Research Laboratory.

In 2004, reports stated that 40% of military members experience PTSD but only 23% seek medical help. Emory physicians described one of the strongest indicators of PTSD to be avoidance, saying this inhibits those affected from seeking treatment.[21] PE requires that the patient close their eyes and relate the pertinent episode in as much detail as possible. The methodology was based on the concept that in facing the event, the charge of the triggers may be attenuated over time. The VRET application BRAVEMIND differs from PE in that the patient does not reimagine the episode but instead wears a headset that places them in the familiar environment. This headset is equipped with two screens (one for each eye), headphones, and a position monitor that shifts the visual scene to match the patient’s head movements. Depending on the patient’s experience they may be standing or sitting on top of a raised platform with a bass shaker. This allows for vibrations that simulate the experience of riding a military vehicle. Other accessories such as joysticks or mock machine guns are given to the patients, if appropriate, to enhance realism.[20]

The clinician introduces triggers, such as gunfire, explosions, etc.  into the virtual environment as they see fit. The clinician can also adapt sound and lighting conditions to match the patient’s description. The researchers who developed the BRAVEMIND system reported that in a 20-patient trial, the patients’ scores on the diagnostic PTSD checklist–military version (PCL-M) dropped from 54.4 pre-treatment to 35.6 post-treatment after eleven sessions. In another clinical trial, consisting of 24 active-duty soldiers, it was reported that after 7 sessions 45% no longer were identified as positive for PTSD while 62% demonstrated symptomatic improvement. These experimental results were compared with those of alternative PE treatments.[19]

The BRAVEMIND software has 14 different environments available including military barracks, Iraqi markets, and desert roads.[21] Included in these are environments specific to military sexual trauma (MST). Designed environments such as U.S. base settings, shower areas, latrines, remote shelters, and others were developed after consulting subject matter experts from Emory University.[19]

Proponents of this research have said that with military based videogames being so prevalent, this technology may be more appealing to patients and reduce the stigma surrounding treatment. They also have argued that as research on PTSD unfolds, possible subtypes may respond to treatments differently, and therefore diversifying treatment options is best.[21] Others have expressed reservations about the capacity to properly personalize VRET for individualized treatment and the use of ethnic stereotyping while developing Arab populated environments.[20]

Depression[edit]

In February 2006 the UK's National Institute of Health and Clinical Excellence (NICE) recommended that VRT be made available for use within the NHS across England and Wales, for patients presenting with mild/moderate depression, rather than immediately opting for antidepressant medication.[23] Some areas have developed, or are trialing.

At Auckland University in New Zealand, a team led by Dr. Sally Merry have been developing a computerized CBT fantasy "serious" game to help tackle depression amongst adolescents.[24] The game, Sparx, has a number of features to help combat depression, where the user takes on a role of a character who travels through a fantasy world, combating "literal" negative thoughts and learning techniques to manage their depression.

Eating disorders and body dysmorphia[edit]

Virtual reality therapy has also been used to attempt to treat eating disorders and body dysmorphia. One study in 2013 had participants complete various tasks in virtual reality environments which could not have been easily replicated without the technology. Tasks included showing patients the implications of reaching their desired weight, comparing their actual body shape to an avatar created using their perceived body size, and altering a virtual reflection to match their actual body size.[25]

Acrophobia[edit]

The study published in The Lancent Psychiatry [26] proved that Virtual Reality therapy can help treat the Acrophobia.[27][28][29]

Occupational therapy[edit]

Autism[edit]

Virtual reality has been shown to improve the social skills of young adults with autism. In one study, participants controlled a virtual avatar in different virtual environments and maneuvered through various social tasks such as interviewing, meeting new people, and dealing with arguments. Researchers found that participants improved in the areas of emotional recognition in voices and faces and in considering the thoughts of other people. Participants were also surveyed months after the study for how effective they thought the treatments were, and the responses were overwhelmingly positive.[30] Many other studies have also explored this occupational therapy option.

Post traumatic stress disorder[edit]

It may also be possible to use virtual reality to assist those with PTSD. The virtual reality allows the patients to relive their combat situations at different extremes as a therapist can be there with them guiding them through the process. Some scholars believe that this is a great way to treat these patients as it allows for the recreation of exactly what they went through. "It allows for greater engagement by the patient and, consequently, greater activation of the traumatic memory, which is necessary for the extinction of the conditioned fear."[31]

Stroke patients[edit]

Virtual reality also has applications in the physical side of occupational therapy. For stroke patients, various virtual reality technologies can help bring fine control back to different muscle groups. Therapy often includes games controlled with haptic-feedback controllers that require fine movements, such as playing piano with a virtual hand.[32] The Wii gaming system has also been used in conjunction with virtual reality as a treatment method.[33]

Efficacy[edit]

Randomized, tightly controlled, acrophobia treatment trials at Kaiser Permanente provided >90% effectiveness, conducted in 1993–94. (Ext. Ref. 2, pg. 71) Of 40 patients treated, 38 showed marked reduction in phobic reaction to heights and self-reported reaching their goals. Research found that VRT allows patients to achieve victory over virtual height situations they could not confront in real life, and that gradually increasing the height and danger in a virtual environment produced increasing victories and greater self-confidence in the patient that they could actually confront the situation in real life. "Virtual therapy interventions empower people. The simulation technology of virtual reality lends itself to mastery oriented treatment ... Rather than coping with threats, phobics manage progressively more threatening aspects in a computer-generated environment ... The range of applications can be extended by enhancing the realness and interactivity so that actions elicit reactions from the environments in which individuals immerse themselves" (Ext. Ref. 3, pg. 331–332).

Another study examined the effectiveness of virtual reality therapy in treating military combat personnel recently returning from the current conflicts in Iraq and Afghanistan. Rauch, Eftekhari and Ruzek conducted a study with a sample of 42 combat servicemen who were already diagnosed with chronic PTSD (post-traumatic stress disorder). These combat servicemen were pre-screened using several different diagnostic self-reports including the PTSD military checklist, a screening tool used by the military in the determination of the intensity of the diagnosis of PTSD by measuring the presence of PTSD symptoms. Although 22 of the servicemen dropped out of the study,[why?] the results of the study concerning the 20 remaining servicemen still has merit.[why?] The servicemen were given the same diagnostic tests after the study which consisted of multiple sessions of virtual reality exposure and virtual reality exposure therapy. The servicemen showed much improvement in the diagnostic scores, signaling a decrease of symptoms of PTSD. Likewise, a three-month follow-up diagnostic screening was also administered after the initial sessions that were undergone by the servicemen. The results of this study showed that 15 of the 20 participants no longer met diagnostic criteria for PTSD and improved their PTSD military checklist score by 50% for the assessment following the study. Even though only 17 of the 20 participants participated in the 3-month follow-up screening, 13 of the 17 still did not meet the criteria for PTSD and maintained their 50% improvement in the PTSD military checklist score. These results show promising effects and help to validate virtual reality therapy as an efficacious mode of therapy for the treatment of PTSD (McLay, et al., 2012).

Continued development[edit]

Larry Hodges, formerly of Georgia Tech and now Clemson University[34] and Barbara Rothbaum of Emory University, have done extensive work in VRT, and also have several patents and founded a company, Virtually Better, Inc.

In the United States, the United States Department of Defense (DOD) continues funding of VRT research[35] and is actively using VRT in treatment of PTSD.[citation needed]

Treatment for lesions[edit]

Virtual reality therapy has two promising potential benefits for treatment of hemispatial neglect patients. These include improvement of diagnostic techniques and as a supplement to rehabilitation techniques.

Current diagnostic techniques usually involve pen and paper tests like the line bisection test. Though these tests have provided relatively accurate diagnostic results, advances in virtual reality therapy (VRT) have proven these tests to not be completely thorough. Dvorkin et al. used a camera system that immersed the patient into a virtual reality world and required the patient to grasp or move object in the world, through tracking of arm and hand movements. These techniques revealed that pen and paper tests provide relatively accurate qualitative diagnoses of hemispatial neglect patients, but VRT provided accurate mapping into a 3-dimensional space, revealing areas of space that were thought to be neglected but which patients had at least some awareness. Patients were also retested 10 months from initial measurements, during which each went through regular rehabilitation therapy, and most showed measurably less neglect on virtual reality testing whereas no measurable improvements were shown in the line bisection test.[36]

Virtual reality therapy has also proven to be effective in rehabilitation of lesion patients suffering from neglect.[37] A study was conducted with 24 individuals suffering from hemispatial neglect. A control group of 12 individuals underwent conventional rehabilitation therapy including visual scanning training, while the virtual reality group (VR) were immersed in 3 virtual worlds, each with a specific task. The programs consisted of

  1. "Bird and Ball" in which a patient touches a flying ball with his or her hand and turns it into a bird
  2. "Coconut", in which a patient catches a coconut falling from a tree while moving around
  3. "Container" in which a patient moves a box carried in a container to the opposite side.

Each of the patients of VR went through 3 weeks of 5-day-a-week 30-minute intervals emerged in these programs. The controls went through the equivalent time in traditional rehabilitation therapies. Each patient took the star cancellation test, line bisection test, and Catherine Bergego Scale (CBS) 24 hours before and after the three-week treatment to assess the severity of unilateral spatial neglect. The VR group showed a higher increase in the star cancellation test and CBS scores after treatment than the control group (p<0.05), but both groups did not show any difference in the line bisection test and K-MBI before and after treatment. These results suggest that virtual reality programs can be more effective than conventional rehabilitation and thus should be further researched.

Advantages[edit]

The preference of virtual reality exposure therapy over in-vivo exposure therapy is often debated, but there are many obvious advantages of virtual reality exposure therapy that make it more desirable. For example, the proximity between the client and therapist can cause problems when in-vivo therapy is used and transportation is not reliable for the client or it is impractical for them to travel as far as needed. However, virtual reality exposure therapy can be done from anywhere in the world if given the necessary tools. Going along with the idea of unavailable transportation and proximity, there are many individuals who require therapy but due to various forms of immobilizations (paralysis, extreme obesity, etc.) they can not physically be moved to where the therapy is conducted. Again, because virtual reality exposure therapy can be conducted anywhere in the world, those with mobility issues will no longer be discriminated against. Another major advantage is fewer ethical concerns than in-vivo exposure therapy. Once again, considering the idea of close proximity no longer being a requirement, this decreases the chances of inappropriate client-therapist relations taking place.[citation needed]

Another advantage to virtual reality rehab over the traditional method is patient motivation. When presented with difficult tasks during a prolonged period, patients tend to lose interest in these tasks. This causes a decrease in compliance due to decreased motivation of completing a given task. Virtual reality rehab is advantageous in such a way that it challenges and motivates the patient to do more. With simple things like high scores, in-game awards, and ranks, not only are patients motivated to do their daily therapies, they are having fun doing it.[38] Not only is this advantageous to the patients, it is advantageous to the physical therapist. With these high scores, and data the game or application collects, therapists can analyze the data to see progression. This progression can be charted and visually shown to the patient for increased motivation on their performance and the progression they have made thus far in their therapies. This data can then be charted with other participants doing similar tasks and can show how they compare to people with similar therapy regimens. This charted data in the program or game can then be used by researchers and scientists alike for further evaluation of optimal therapy regimens. A recent study done in 2016 where a VR based virtual simulation of a city named Reh@City was made. This city in virtual reality evoked memory, attention, visuo-spatial abilities and executive functions tasks are integrated in the performance of several daily routines. This study looked at Activities of Daily Living in post stroke patients and found it to have more of an impact than conventional methods in the recovery process.[39]

Concerns[edit]

There are a few ethical concerns concerning the use and development of using virtual reality simulation for helping clients/patients with mental health issues. One example of these concerns is the potential side effects and aftereffects of virtual reality exposure. Some of these side effects and aftereffects could include cybersickness (a type of motion sickness caused by the virtual reality experience), perceptual-motor disturbances, flashbacks, and generally lowered arousal (Rizzo, Schultheis, & Rothbaum, 2003). If severe and widespread enough, these effects should be mitigated via various methods by those therapists using virtual reality.

Another ethical concern is how clinicians should receive VRT certification. Due to the relative newness of virtual reality as a whole, there may not be many clinicians who have experience with the nuances of virtual reality exposure or VR programs' intended roles in therapy. According to Rizzo et al. (2003), virtual reality technology should only be used as a tool for qualified clinicians instead of being used to further one's practice or garner an attraction for new clients/patients.

Some traditional concerns with virtual reality therapy is the cost. Since virtual reality in the field of science and medicine is so primitive and new, the costs of virtual reality equipment would be a lot higher than some of the traditional methods. With medical costs growing at an exponential level this would be another cost that is added to the growing list of medical bills for a patients recovery process. Regardless of the benefits with virtual reality rehab, the costs of the equipment and the resources for a virtual reality setup would make it difficult for it to be mainstream and available to all patients including the indigent population.

References[edit]

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