Simulation for Therapy

Traditional Therapeutic Techniques

Simulation for therapy deals a lot with Posttraumatic stress treatments and assisting people with alleviating different types of fears as well as anxiety and social phobia treatment. These areas of therapy rely on techniques involving systematic desensitization [ [systematic desensitization] ], flooding [ [Flooding (Psychology)] ]and other immersion techniques to put clients into the situation in varying levels of fidelity. Research shows that these trauma-focused treatments work well in the treatment of these types of disorders. Therefore, it is useful to focus on the phobia, trauma, instead of just non-specific stress-management techniques (Ehlers, et al., 2008)

In traditional therapy for example, a client may state that he/she is afraid of Dogs and traditionally the therapist may start by showing the client a picture of a dog and rate how fearful that is or bring the client into a room where there is a dog in a kennel and rate that experience. Or if the client states that he/ she is afraid of speaking in public they might have the client give a sentence speech in front of an empty audience then start increasing the audience until the client was comfortable with given an entire speech in front of a crowd. During those experiences, the therapist would then help the client practice relaxation or other cognitive and/or behavioral techniques. This allows the therapist to start with situations that may be only uncomfortable for the client and ease into situations that would otherwise be frightening. In addition, in some situations clients can also go through visualization exercises to picture the fearful stimuli as something less fearful. For example, In a research study students who were fearful of spiders were asked to think of them as rubber and squeaked when squeezed, then were asked to think of uses for them, such as dog toys etc… this group of people also completed mad libs about the spiders (Ventis et al., 2001).

Simulation Based Approaches

Simulation used for therapy can be a viable option as either the entire treatment process or as a smaller part of a larger more traditional therapy.  Especially when the client has a fear that cannot be fear that dealt with traditional methods either due to being too expensive or dangerous.  For example, a client who wants to go sky diving and is too afraid to go through with it or a soldier that was diagnosed with Post-traumatic Stress Disorder (PTSD).

Virtual Reality Exposure Therapy (VRET)

One way to use simulation for therapy is to use Virtual Reality Exposure Therapy (VRET). This technique has been found as effective as traditional based therapy and this technique is can be customized for specific phobias. This technique has also been found highly effective when compared to no treatment groups (Meyerbroeker and Emmelkamp, 2010) . The type of therapy that comprises VRET can vary from using a computer program to full emersion into a virtual environment while wearing a headset and sensors (Williams & Nicholas, 2010) . For example, in the case of fear of speaking in public the therapist could have the client talk in front of varying sized audiences. However, that might be hard to accomplish, either to rent a space for the speech or find an audience that is patient and willing to sit through many different speeches, or one that is available every time the client is. If that same therapist puts the client, into simulator, that person can experience a realistic experience of speaking in public and the therapist can control the audience by simply changing the settings.

Treatment of Specific Phobias

Driving

Another area which is used for simulated therapy is driving exposure therapy. Many think that it can be safer than driving on streets or highways for several reasons. Williams and Nicholas (2010) . stated that many people who have had driving accidents may stop driving or take different routes in order to avoid traffic. They also try to suppress thoughts of the accident and feel that the world is a much more dangerous place. Going for a drive to the scene of the accident may be too fearful and could possibly make that person a worse driver due to that fear. However, someone experiencing that phobia can get into a realistic looking simulation of a car, drive virtually, and work on decreasing their anxiety by being exposed to varying levels of realism with the guidance of a therapist. Also, since the therapist can vary the levels of weather, traffic, time of day, type of roads etc… the patient can experience situations that are less fearful at first and gradually decrease that fear. One specific example of its use is a case study completed by Wald and Taylor, (2000) . They used a case study design and studied a single patient who experienced anxiety and fear at the thought of driving. They established a baseline anxiety level with driving in a simulator and they gave her three treatment sessions over a ten-day period where they had her drive in a simulator and following the drive she recorded her thoughts and fears in a driving diary, which she studied during the week. In every session, she would move to a higher anxiety-provoking scenario and her pre and post anxiety levels were measured. The therapist measured a significant decrease in anxiety levels felt during driving throughout the progression of the scenarios.

Anorexia Nervosa

Simulation has also been used to treat Anorexia Nervosa. In one case study, a university student used Virtual Reality assisted therapy to decrease her level of body dissatisfaction. While in the Virtual Reality sessions, the patient was able to visualize her body at different sizes and in different situations. The sessions were used for both guided imagery and to discover the triggers of anxiety related to her food exposure (Riva et al., 1999) .

Job Interview skills

One study looked at the frequency of stuttering during challenging and supportive job interviews. This study was conducted in a simulated virtual reality mainly because it was easier to control and use for job interviews that recruiting people for the task. It also allowed a safe confidential environment in which patents’ receiving treatment would be willing to open up and work on their issues. If people were used the patient would possibly be more reserved and resistant to treatment. (Brundage et al., 2006) . Twenty-three people interacted with a virtual interviewer. In this interaction

People could both interview with a man or woman and have either a challenging or a supportive interview. In the challenging interview diplomas are shown on the wall and in the supportive the walls are more Spartan. In addition, in the challenging interview the virtual interviewer would often speak to quickly and not make eye contact whereas in the supportive interviews the opposite is true.

Physical Therapy

Virtual Reality Therapy for the physically disabled is an area that simulation is starting to explore. It is useful to people showing dysfunction of a specific area, such as speech or movement where individuals are able to perform certain actions and get feedback on those actions.

For individuals who have problems with movement virtual scenarios can be created that gradually go from easy to difficult in order to train that individual to walk again (Kuhlen and Dohle, 1994) . Much as a weight lifter may, start at 100 lbs weights and then every session increase 10 lbs until he or she can lift a full 200 lbs.

“within virtual worlds paralyzed people are able to perform the same complex tasks as non-handicapped  people  using  input  devices  that  are  well  suited  to their  remaining motor capabilities.” .  “Also, Assistive technology devices have already been developed that measure minimum human output” such as the use biofeedback and EEG/EMG in order to display and assist the person in the virtual world (Kuhlen and Dohle, 1994) .

       Physicians also benefit from VRET by using visualization systems that allow them to watch the patient’s movements while they are inside of the virtual environment and use that information to help the doctor diagnose the problem and to plan therapy for the patient based on that information (Kuhlen and Dohle, 1994) .

Nintendo WII

(See Wii)

Wii Therapy

Therapists are starting to use the video game console WII in therapy. Back in 2001, not many people would have thought that the game platform would be used for so much more than just playing games, however the motion sensing technology embedded in the system makes it useful in many contexts. In addition, add-ons to the system make it more and more useful in therapeutic ways such as the motion-plus, which makes the system more sensitive and the WII balance board, which contains multiple pressure sensors that can calculate a users’ center of balance (Butler and Willett, 2010) . It is also possible that the Wii will be used for therapy in larger VRET environments as researchers use the Wii remotes as an Infrared-optical tracking system. Tracking systems can be very expensive and cumbersome (some being $8–10,000) however the Wii makes a cheaper alternative (Amici, et al., 2010) ..

Wii Therapy for Rehabilitation

In 2007, the Wii showed some evidence that it helped post-stroke patients’ to rehabilitate and after that, its use in therapy gained popularity in national newspapers and then moved its way into peer-reviewed journals. The first case in the peer-reviewed literature is its use over an 11-week period to help the rehabilitation of a 13-year-old male with cerebral palsy (Butler and Willett, 2010) .

Wii Therapy for Disabilities

Recently, researchers have used the Wii to help people with multiple disabilities to control their environment using the Wii Remote control (WiiMote). These researchers combined the WiiMote with a Limb action detection program to enable to detect where a patients limbs are at any point in time. The participants were two teenagers aged 17 and 19 who both suffered from multiple disabilities including lack of speech and movement difficulties. In the study, they had WiiMotes fixed to their arms and legs and when they performed a correct target action, they would be rewarded by having the TV turn on and they were able to watch their favorite shows (Shih, et al., 2010). .

Another example of a recent use of the Wii for therapy comes from another researcher who evaluated the Wii Nunchuk as an alternative device for individuals with both intellectual and physical disabilities. Many people with this kind of disabilities have a hard time using standard computer interface devices such as keyboards and mice and custom-made peripherals are expensive and hard to manufacture. Again, the Wii makes a cheap useful alternative to assist these individuals. Researchers in this study had 23 people compare the Wii Nunchuk with their current joystick and they found that there were no differences between the two (Standen et al., 2010) . This means that the WiiMote with the Nunchuk attachment may be a cheaper and just as good alternative to the custom-made joysticks the participants were using before the study. This research has shown that the Wii system can possibly be used as a therapeutic device and used for simulation-based therapy.

Simulation Based Therapy for Post Traumatic Stress Disorder (PTSD)

One of the largest uses of Simulation for Therapy is it help treat people suffering from Post Traumatic Stress Disorder (PTSD). “A subset of people who experience a terrifying, potentially deadly physical or emotional incident develop chronic psychological problems such as PTSD” (Josman et al., 2008) . A study conducted in 2004 showed that 71-86% of deployed soldiers have been engaged in firefights and 50-57% has reported they either uncovered or handled human remains (Reger and Gahm, 2008) . This is especially true of soldiers returning from combat. In addition, since soldiers have unique experiences during combat that are difficult to replicate using traditional methods or exposure and desensitization therapy simulation the treatment is very helpful. It is also, advantageous because treatment programs using VRET are completely customizable for each individual in order to maximize the therapeutic efficacy of the treatment.

Examples of Exposure Therapy

Busworld is one program that seeks to help who have developed PTSD after witnessing a terrorist suicide bombing on a bus. The simulation allows for varying levels of realism. In the first level, participants witness a view of a bus stop. The second level adds a bus pulling up to the stop. At the third level, the bus explodes, however, there is no sound and the visual is not realistic and finally the fourth level is a fully realistic version of the scene with full sounds of the explosion and people screaming, as well as a police response (Josman et al., 2008) . Researchers use this simulation to desensitize patients to the situation. The efficacy of VRET for PTSD are mostly evaluated using case studies where one person who is suffering from PTSD is treated using VRET and then retested for PTSD symptoms during and after treatment to determine if the treatment was effective and if the individual maintained his or her progress after the cessation of treatment. The patients who take part in the case studies generally report a reduction of symptoms after treatment and seem to retain those benefits when retested after 6 months (Reger and Gahm, 2008) . VRET seems to be an effective treatment that is easy to administer to patients in order to reduce symptoms.

Other Therapeutic Uses

Pain Management

Phantom Limb Pain

Another use of simulation for therapy is for pain management therapy. Either for long-term management or for short term. One example of this is the mirror box, created by Ramachandran, M.D. Ph.D., where patients who had recently lost a limb (arm or leg) and still experienced Phantom pain or even itches in the limb(s) that did not exist anymore. Some patients would complain of very severe clenching or other pains that they would have for years and were never able to fix. In order to solve the problem they put both limbs in a box filled with mirrors this gave the illusion that the patient had both limbs intact and then they were able to relieve that pain by having the visual sensation that they were itching the limb that was not there. After experiencing the mirror box, most patients reported much less pain during the case studies. This is happens since phantom limb pain is caused a rewiring of either the nerves or in the somatasensory cortex in the parietal lobe of the brain. When a pathway is not being used, the body will reuse it for something else. This rewiring causes there to be sensory input to areas that once controlled the missing limbs and causes the patient to feel pain or other sensations in the limb(s) and because the limb are missing, there are no signals to stop that sensory input or even a way for the patient to scratch his or her itch. However, the visual system offers the body powerful feedback and by getting that feedback through the mirror box, the patients can stop that stray sensory input and thus stop the pain (Ramachandran and Blakeslee, 1999)..

VR Anesthesia

	One study shows the benefits of using it as “VR Anesthesia”   The more immersed the Patient becomes into the virtual world the more he or she feels a part of it and possibly that immersion may decrease the pain the patient feels as he or she is undergoing a medical procedure.  Prior research as shown that distraction is helpful as pain management and future studies can explore the VRET immersion as “VR Anesthesia” but as of now the research into the topic is still in its infancy (Gold, et al., 2005) .

Training Therapists

Finally, Simulation is also a technique that researchers are using to better train therapists. Understanding patients is something that is not always possible without the use of simulation. For Example, Individuals experiencing a psychiatric disorder such as schizophrenia experience such symptoms as both auditory and visual delusion, and hallucinations as well as other symptoms that the therapist treating the individual, in most cases, has never experienced for themselves. This lack of personal experience of the therapist of the symptoms their patients are experiencing can lead to problems understanding their clients especially since up to 12-16% of hospital beds in some countries are diagnosed with the disease. Simulation can step in these situations and show these symptoms to the therapist who can then use that information to better diagnose and treat individuals with the disease. Future research looks on how to show better images in full 3D to make the experience more realistic (Banks, et al., 2003) .