“It was an idea whose time had come, and the technology finally caught up with the vision.” -Albert “Skip” Rizzo, Ph.D.
If you’re at all familiar with VR, you’ve probably heard that VR is more than “just games” a time or two. Used to describe applications of VR that go beyond first-person shooters—think education, conservation, training, etc.—the phrase is something that many in the industry intuitively understand. Still, it continues to merit saying, especially when we talk about the research and clinical practice of virtual reality in cognitive and physical therapy treatment by leading psychologists and clinicians—which goes way beyond gaming; it has the potential to change the way we think about therapy altogether.
Despite the recent surge in VR development over the last few years, the idea of using virtual reality in a therapeutic setting isn’t a new idea. Research regarding VR simulations to treat specific phobias was around as early as the nineties, but the technology simply wasn’t advanced enough for such treatment to be feasible. Head mounted displays were clunky, computer processing speeds laughable, and 3D graphics downright primitive in comparison to what’s available VR today. Perhaps even more importantly: the technology required for advanced VR in the 90s was too costly to ever be seriously considered for mass distribution.
Clearly, things have changed.
“We’re seeing more companies emerge in the last two years than we’ve seen in the last twenty years,” said Skip Rizzo, Ph.D, director for medical virtual reality at the USC Institute for Creative Technologies. “It was an idea whose time had come, and the technology finally caught up with the vision.”
An unlikely contributor led the way in funding and support for VR therapy research: the US military. Operation Iraqi Freedom led to an unforeseen number of troops returning home from the battlefront with physical and emotional trauma, prompting the military to seek out new, innovative treatment options for their soldiers and vets—especially those suffering from Post-Traumatic Stress Disorder.
Virtual Iraq VRET was developed from 2005-2007 as an answer to the military’s problem at USC’s Institute for Creative Technologies. During the early stages of development, Rizzo considered different treatment options, but eventually decided on exposure therapy for the project.
“Whenever I design a VR application in a clinical area, I look at, okay, what do we know works in the real world that we can use VR to amplify, or extend the effect?” said Rizzo. “Exposure therapy was a no brainer.”
Exposure therapy employs the patient’s imagination and memory to actively engage with their “triggers” or source of trauma, as opposed to avoiding it. With time, prolonged exposure to the trauma lessens its hold on the individual.
Though traditional exposure therapy is the most widely accepted therapy for PTSD, it has its limitations. Some patients are unwilling or unable to recount the traumatic narrative, resulting in ineffective treatment. VR enhances the treatment by allowing patients and clinicians to take the guesswork out of the experience by dropping them into a virtual scenario that is tailored to their individual experience. In VR, the patient is fully emotionally immersed in the traumatic situation while physically remaining in a safe, controlled setting. The use of VR in exposure treatment also enhances the experience for the therapist, who can view the experience on a screen and witness first-hand what exactly triggers the patient, along with listening to the patient’s recollection of the event.
Over time, Virtual Iraq VRET advanced and morphed into project BRAVEMIND, which yielded exceedingly positive results through clinical trials. BRAVEMIND is now being used in VAs, university clinics, and Army, Navy, and Airforce medical centers to treat PTSD patients.
“A little known secret is, since we’ve been doing the work, the two iterations of the exposure therapy system have been deployed to over a hundred sites,” said Rizzo.
Despite the wide distribution, he hesitates to call VR therapy mainstream just yet, saying instead that “it’s right at the tipping point.”
Since its creation, BRAVEMIND has expanded to include treatment scenarios for PTSD in combat medics and victims of military sexual assault. Psychologists are also researching ways that VR can be used in PTSD diagnosis as well as treatment. As Rizzo’s team looks to expand the therapy to non-combat related PTSD patients, the potential seems limitless.
“We’re finding out new things all the time,” he said.
Though PTSD treatment is a pretty strong focus of research for many VR therapists, in part due to support and funding from the US military, psychologists have also successfully incorporated virtual reality into treatment for patients with a number of other physical and cognitive disorders. For example, the very nature of VR makes it an extremely effective tool for treating patients with phobias—something that the Virtual Reality Medical Center has been doing for the past 21 years.
While many VR therapy treatment options are still in conceptual or testing phases, the VRMC has treated a staggering number of cases across its three US based clinics since it first opened its doors.
“I’ve conducted over 10,000 VR therapy and training sessions,” said VRMC President Dr. Brenda K. Wiederhold, Ph.D., MBA, BCB, BCN.
Using VR-enhanced Cognitive Behavioral Therapy in which patients are taught breathing with biofeedback techniques that are applied in the VR world, the team of psychologists have successfully treated patients with a fear of needles, claustrophobia, fear of public speaking, flying related anxiety, and more. Patients treated at VRMC often have phobias so severe that facing their fear—be it spiders, blood, flying, etc.—in the real world would be simply inconceivable. VR gives people with phobias the ability and power to confront their fears head on in a virtual setting.
“It’s empowering for the patient,” said Wiederhold.
VR therapy treatments for PTSD and phobias are similar in that they use the virtual environment to have the patient confront their fear or trauma in a safe, controlled setting. However, VR can be applied in completely different ways to treat other disorders like depression. An innovative study by UCL Barcelona professor Chris Brewin used a “body switch” method to help alleviate depression symptoms in a small, controlled trial.
Depressed patients entered a VR world in which there was a crying child who needed their help. After the patients consoled the child, they virtually switched bodies with the child and heard their own voice through an avatar consoling them. Though the study showed overwhelmingly positive results, the small trial lacking a control group needs extensive further testing and research before it can be used regularly as a treatment for people with depression.
Other methods of VR depression treatment are being explored by The VR Therapy Center in Grand Rapids, MI. Since it opened in January 2015, the center has treated over 300 patients suffering from depression using VR. Founded by psychotherapist Thomas J. Overly, LMSW, the clinic’s team has found that VR treatment is most effective in patients with comorbid depressive symptoms; 75% of the patients treated at the clinic have depression symptoms that are connected to other behavioral or interpersonal issues such as PTSD. The therapy has improved depressive symptoms in many patients, but Overly and his team are on a mission to improve upon the current platforms available for VR depression treatment.
Enter PromenaVR: a software system designed by Overly that allows clinicians to actually enter the VR environment with patients and have customized, two-way interactions with them inside of the virtual world. The experience is tailored so that the clinician appears as any race, gender, age, or body type depending on the specific needs of the patient, creating a “story that is their story.”
Settings range from a casual living room to open public spaces. Currently in beta, the software system was created “to treat depression and comorbidity issues that aren’t being addressed in typical VR therapy platforms that are available right now,” said PromenaVR COO, CMO Tanya Kellen. While not being used to treat patients just yet, the team at VR Therapy Center and PromenaVR believes that the interactive, two-way immersion system is the key to successfully treating depression using virtual reality in the future.
From PTSD, phobia, depression treatment and beyond, it’s clear that the future of VR therapy is extremely bright. Though it’s unclear how or when the technology will finally “go mainstream,” Rizzo predicts that it will do so in waves, with VR pain management therapy as the first to really be accepted as standard practice nationwide.
“I think in the next year you’re going to see more and more hospitals using VR for pain distraction or discomfort reduction,” said Rizzo.
VR is a tool that has the power to change the way we think about therapy, but at the end of the day, Rizzo believes that it is just that—a tool.
“In one sense, VR offers some magic in delivering this type of content, but, we’re always operating from a base of what we know works in the real world,” said Rizzo. “How can we do it better, more effectively, more consistently, and in a more engaging way.”
In other words, VR won’t replace the expertise and care of psychologists and psychiatrists or the tried and true techniques in therapy that have been used for decades. But it can—and will—improve and enhance the therapy experience in ways that haven’t even been imagined yet. After all: “It’s a revolution.”