Virtual Reality Therapy:
On Your Desktop Today
Dr. Luo is assistant clinical professor in the Department of Psychiatry and Biobehavioral Sciences at the University of California in Los Angeles; past president of the American Association for Technology in Psychiatry (AATP) in New York City; and Gores Informatics Advocacy chair at the AATP.
Disclosure: Dr. Luo reports no affiliation with or financial interest in any organization that may pose a conflict of interest.
For many clinicians, the use of virtual reality (VR) in psychiatric practice better resembles a movie scene than their everyday experience. However, today’s computer hardware and software has sufficiently improved enough to create a virtual world in the typical office. In particular, with computer central processing units following Moore’s Law—transistor density of circuits doubles every 18 months for the same cost—computers today have the capability of processing large amounts of information quickly enough to produce sufficient visual stimulation in simulations. Computer games are an example of how visual effects have become a vital component of game play as well as evoking the imagination with various storylines and engaging the player with a breadth of activity. High resolution liquid crystal display and plasma monitors have become more commonplace at home and in the office. These technologies help convey a sense of participation in the virtual world, which may be sufficient in lieu of expensive traditional headsets. These headsets have also matured becoming lighter and better at integrating movement information into the virtual environment at lower costs. This article reviews the history of VR treatment and explores future developments in the field.
In 1995, Rothbaum and colleagues1 reported on the promise of the VR-based treatment of acrophobia. In this controlled study, VR treatment, using graded exposure in a simulated environment, was compared to a wait-list group. Virtual environments included footbridges of 7, 50, and 80 meters above water; outdoor balconies on the ground, 2nd, 10th, and 20th floors of a building; and a glass elevator rising 49 floors. The study screened >400 students and found 20 students with significant fear and avoidance of heights. Several rating measures including an Acrophobia Questionnaire, Attitude Towards Height Questionaire, and a Rating of Fear Questionnaire were used. Students in the virtual treatment group demonstrated statistically significant attitude improvement toward heights. Although it was not part of the study, seven out of 10 students in the VR treatment group felt confident enough to expose themselves to height situations in vivo between sessions.
Hardware consisted of a head-mounted display with electromagnet sensors to track head and right hand movements. A Silicon Graphics Indigo graphics workstation, which in 1994 cost approximately $55,000,2 ran simulations. The head-mounted display cost $1,000.3 Since commercially available systems were not available in 1995, virtual environment development costs could not be determined. The majority of code was written by the faculty and graduate students at Georgia Tech University. A computer programmer consultant may cost >$10,000.
A key factor in successful simulation is the ability to generate “presence,” or the sense of physically “being there.”4 Although visual stimulation plays a critical role in establishing presence, involvement of more than one sense, particularly hearing, can further establish presence. In 1999, Rothbaum5 presented data on the simulation of Vietnam for treatment of posttraumatic stress disorder. In anecdotal comments, American Vietnam War veterans indicated that the sound of helicopter blades evoked the most distress. Rand and colleagues6 indicated that VR system characteristics, such as dimensionality, representation, and mulitimodality; user characteristics, such as age, gender, and immersive tendencies; and VR environment and task characteristics, such as realism, meaningfulness, and interaction, impact perception of presence. Granito7 presented research on head-mounted displays versus translucent screens on the impact of presence. Translucent screens create a three-dimensional stereo effect by displaying in alternating succession the left and right eye views of the scene as rendered from the viewer’s perspective. War veterans participating in the study7 indicated that the head-mounted display was more engrossing than watching an interactive screen. Another method of establishing presence is to create an immersive environment with projections on several walls in a small room.8
Virtual Reality Treatment
Anxiety disorders are the most common disorders treated with VR therapy, but there are numerous conditions where VR therapy can be helpful. VR has been used to treat fear of flying, driving, public speaking, heights, spiders, thunderstorms, needles, blood, and closed or open spaces as well as flying anticipatory anxiety, school and social phobia, attention-deficit/hyperactivity disorder, panic disorder, and addiction disorders.9 VR therapy has been successful due to its ability to help patients with visualization difficulties and difficulty with in vivo treatment due to extreme phobias and anxiety. VR therapy has also been used to treat eating disorders10 and erectile dysfunction.11
In a 3-year follow-up study on fear of flying, Wiederhold and Wiederhold12 demonstrated that VR cognitive-behavioral therapy (CBT) is more effective with this phobia than visualization, and it is as effective as real-life therapy. Recidivism rates are reduced and therapeutic effectiveness have been enhanced by adding physiologic monitoring and feedback to VR CBT. Results from the 3-year follow-up data analysis from a controlled study evaluating fear of flying indicated that VR CBT with physiologic monitoring results in lower relapse rates than VR CBT alone.
VR therapy is currently being studied as a tool to help people stop smoking at Emory University and the University of Georgia.13 Volunteers are separated into two groups both using nicotine patches to facilitate smoking cessation; however, one group participates in weekly VR sessions known to trigger cigarette cravings. These sessions have visual, auditory, and olfactory triggers at various places, such as restaurants, office courtyards, and in virtual cars, while a study therapist teaches participants relapse prevention and coping skills.
The power of computers has improved dramatically over the past 10 years. The graphic capability formerly available only on expensive workstations can now be used on a readily available and lower cost computer. Improved graphics hardware has been driven by the development of new computer graphics chips. Two chipmakers, NVidia and ATI, have developed specialized graphics processors with higher speeds, more memory, and multi-threading capability to enhance processing, which has led to the ability to create virtual worlds on the personal computer.
One of the first commercially available virtual worlds was the video game “The Sims,” which was developed by Maxis in 2002. In this game, players can develop characters and make decisions, such as selecting a job or school. During residency at the University of California, Davis, Richard Montgomery, MD (oral communication, 2002) used this game in psychotherapy to help a teenage patient better express issues and address situations differently at home.
Virtual communities can also help patients provide mutual support. Bers14 described the use of Zora,15 an identity construction environment specifically designed to help young people explore issues of identity while engaging in a participatory virtual community. These adolescent patients had end-stage renal disease and were confined to bed while undergoing hemodialysis. The virtual world helped patients connect to one another, using avatars to talk with gestures or real-time text communication. They built virtual rooms and visited one another, which created a sense of community. HutchWorld16 was a virtual community built by the Social Computing Group at Microsoft Research and the Fred Hutchinson Cancer Research Center in 2002. Developers found that Internet access and use of HutchWorld helped study participants improve life satisfaction and social support after bone marrow transplants. Patients were able to participate both in synchronous and asynchronous communication either via chat or 3-D environments, and could send virtual gifts and notes to one another, interact via games, and exploring the environment modeled on an outpatient lobby.17
There are now many online virtual worlds, such as Second Life,18 There.com,19 and ActiveWorlds.20 Second Life has achieved significant attention with its high user number, which is >4.7 million to date. At the Web site, users can write specialized scripts and objects to make clothing or buildings, and companies including Toyota, Starwood Hotels, and American Apparel are utilizing the site.21 The American Cancer Society recently raised $41,000 with a Second Life version of its Relay-for-Life fundraiser.
Healthcare providers can also create a virtual office setting at SecondLife, which can be organized to prevent public access. Although this is not telemedicine, it may be a unique method of providing patient education. Group sessions or support groups could be conducted online in the Second Life office for patients unable to attend in real life due to extreme phobia or travel concerns. Although there are many online communities that provide support, the difference in attending a VR-based meeting is the opportunity for direct interaction between attendees, facilitated through avatars.
VR also shows great promise for medical education. Yellowees and Cook22 developed a Web-based VR simulation system that modeled the auditory and visual hallucinations of two patients with schizophrenia. Using the Second Life virtual environment system to create a virtual psychiatric clinic and ward, programmers modeled hallucinatory experiences in these settings. These experiences included multiple voices criticizing the user, a floor falling away to leave the user stepping on stones in a bank of clouds, and a mirror in which the reflection of the avatar would appear to die. Five hundred and seventy nine (69%) of the users completed a follow-up survey and 440 (76%) of those users felt that the simulation helped their understanding and appreciation of the impact of hallucinations.
Anoli and colleagues23 developed an electronic learning system based on simulations and role playing to help develop communication skills. In this system, the avatar responds to voice commands as the user goes through a medical scenario, such as a patient visiting who does not speak English. The system trains the user to develop better management of emotions during interpersonal communications. At each interactive step of the learning module, the user must choose the most adequate communication choice in order to advance. Users can play different roles as well as serve as tutors in observing the main participant. The computer analyzes each voice for trends to determine its emotional character via machine-learning algorithms. Feedback is provided via an avatar that serves as a coach through the process.
Army research psychologist Major Melba Stez, PhD, has used VR to prepare soldiers for stress in the battlefield.24 By preparing soldiers for stressful situations, such as working as a combat medic, being in a convoy under fire, or street battle, the goal is to decrease the incidence of posttraumatic stress disorder. Stress inoculation via VR therapy moderates the stress-strain relationship by preparing individuals for stressful experiences with coping strategies. It may be that stress inoculation is the one prophylactic against stress as well as serving as good training for specialized job tasks.
Increasing computing power and graphic capabilities have made VR more readily available to clinicians today. It offers unique advantages over in vivo experiences for treatment of many disorders, and virtual worlds provide an opportunity for patients to support one another as well as outreach to loved ones. In the future, VR training may be a new way for medical students to learn how to interview and examine patients. While VR does not replace real-life treatment or learning, it can provide a rich medium to augment real-world experiences. PP
1. Rothbaum RO, Hodges LF, Kooper R, Opdyke D, Williford JS, North M. Effectiveness of computer-generated (virtual reality) graded exposure in the treatment of acrophobia. Am J Psychiatry. 1995;152(4):626-628.
2. Future Technology Research Centre. Available at: www.futuretech.blinkenlights.nl/pcw5-93i2.html. Accessed March 19, 2007.
3. Stereo3d.com. Available at: www.stereo3d.com/hmd.htm. Accessed March 19, 2007.
4. Barfield W, Sheridan T, Zeltzer D, Slater M. Presence and performance within virtual environments. In: Barfield W, Furness TA, eds. Virtual Environments and Advanced Interface Design. Oxford, England: Oxford University Press; 1995:473-513.
5. Rothbaum BO. Virtual reality therapy. Paper presented at: Annual Meeting of the American College of Psychiatrists; February 17–21, 1999; San Francisco, California.
6. Rand D, Kizony R, Feintuch U, et al. Comparison of two VR platforms for rehabilitation: video capture versus HMD. Presence. 2005;14(2):147-160.
7. Granito P. Head Mounted Display vs. Translucid Screen. Available at: www.interactivemediainstitute.com/pdf_2006/S12_Presence/1_Gamito/gamito.pdf. Accessed March 19, 2007.
8. Cruz-Neira C, Sandin DJ, DeFanti TA. Surround-screen projection-based virtual reality: the design and implementation of the CAVE. Comput Graph. 1993;27(2):135-142.
9. Virtual Reality Medical Center. Available at: www.vrphobia.com/therapy.htm. Accessed March 19, 2007.
10. Riva G, Bacchetta M, Baruffi M, Rinaldi S, Molinari E. Virtual reality based experiential cognitive treatment of anorexia nervosa. J Behav Ther Exp Psychiatry. 1999;30(3):221-230.
11. Optale G, Chierichetti F, Munari A, et al. Brain PET confirms the effectiveness of virtual reality treatment of impotence. Int J Impot Res. 1998;10(suppl 1):45.
12. Wiederhold BK, Wiederhold MD. Three-Year follow-up for virtual reality exposure for fear of flying. Cyberpsychol Behav. 2003;6(4):441-445.
13. Baker K. Virtual reality may help smokers kick the habit by combating environmental triggers. Emory Report. January 22, 2007. Available at: www.emory.edu/EMORY_REPORT/pdf/ER_Jan.22.07_web.pdf. Accessed March 19, 2007.
14. Bers MU, Gonzales-Heydrich J, DeMaso D. Identity construction environments: supporting a virtual therapeutic community of pediatric patients undergoing dialysis. Paper presented at: Annual Conference of the Association for Computing Machinery’s Special Interest Group on Computer Human Interaction; March 31–April 4, 2000; Seattle, Washington.
15. Zora. Available at: http://xenia.media.mit.edu/~marinau/Zora/. Accessed March 19, 2007.
16. Farnham S, Cheng L, Stone L, et al. HutchWorld: clinical study of computer-mediated social support for cancer patients and their caregivers. Paper presented at: Annual Conference of the Association for Computing Machinery’s Special Interest Group on Computer Human Interaction; April 20–25, 2002; Minneapolis, Minnesota.
17. HutchWorld Video. Available at: http://research.microsoft.com/scg/presentations/HutchworldDemo.mpg. Accessed March 19, 2007.
18. SecondLife. Available at: www.secondlife.com. Accessed March 19, 2007.
19. There.com. Available at: www.there.com. Accessed March 19, 2007.
20. Activeworlds. Available at: www.activeworlds.com. Accessed March 19, 2007.
21. Carr DF. Second Life: Is business ready for virtual worlds? Baseline. March 1, 2007:31-47.
22. Yellowees PM, Cook JN. Education about hallucinations using an internet virtual reality system: a qualitative survey. Acad Psychiatry. 2006;30(6):534-539.
23. Anolli L, Mantovani F, Agliati A, et al. Simulation-based training of communication and emotional competence for the improvement of physician-patient relationship. Paper presented at: the 11th Annual Cybertherapy 2006 Conference; June 12–16, 2006; Gatineau, Canada.
24. Stez M. Virtual reality stress inoculation training. Available at: www.interactivemediainstitute.com/pdf_2006/S13_Cybertraining/5_Stetz/stetz2006.pdf. Accessed March 19, 2007.