Virtual reality therapy
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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 a method of psychotherapy that uses virtual reality technology to treat patients with anxiety disorders and phobias where it has proven very effective. It is now one of the primary treatments for PTSD. New technology also allows for the treatment of addictions and other conditions including those caused by lesions (Lamson, ext. ref. 2, pp. 108–111).
Virtual reality therapy (VRT) uses specially programmed computers, visual immersion devices and artificially created environments to give the patient a simulated experience 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. 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 where there are simply not enough psychologists and psychiatrists to treat all the veterans with anxiety disorders diagnosed as related to their military service.
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 was done by Ralph Lamson a USC graduate then at Kaiser Permanente Psychiatry Group. Lamson began publishing his work in 1993. 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% 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. 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. 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.
In 2005, Skip Rizzo of USC's Institute for Creative Technologies, with research funding from the Office of Naval Research (ONR), 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.
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).
Larry Hodges, formerly of Georgia Tech and now Clemson University and Barbara Rothbaum of Emory University, have done extensive work in VRT, and also have several patents and founded a company, Virtually Better, Inc.
There are VRT or computerized CBT (CCBT) sessions, some immersive and some not, in which the user interacts with computer software (either on a PC, or sometimes via a voice-activated phone service), instead of face to face with a therapist. For people who are embarrassed by their phobias or feeling depressed and withdrawn, the prospect of having to speak to someone about their innermost problems can be unpleasant. In this respect, VRT/CCBT either in a VR lab or online, is an option. With the huge number of PTSD sufferers and the shortage of available mental health professional, VRT is expanding. New VR therapy sessions are even being done via the well known VR provider Second Life.
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. Some areas have developed, or are trialing.
There are a number of providers currently offering VERT. Some offer interactive communication with therapists and live feedback has shown to improve the result of online VRT/CCBT.
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. The game 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.
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.
Treatment for lesions
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.
Virtual reality therapy has also proven to be effective in rehabilitation of lesion patients suffering from neglect. 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
- "Bird and Ball" in which a patient touches a flying ball with his or her hand and turns it into a bird
- "Coconut," in which a patient catches a coconut falling from a tree while moving around
- "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, 5 days a week, of 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 then conventional rehabilitation and thus should be further researched.
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.
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 issue of some concern is how virtual reality is use by clinicians in that clinicians should be certified to use virtual reality for their clients/patients. Due to the relative newness of virtual reality exposure, there may not be many clinicians who have experience with the nuances of virtual reality exposure and the therapy that virtual reality exposure is meant to be used for. 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. Another ethical issue is the issue of who is developing the virtual reality and thus benefiting from its sale? In terms of the development of virtual reality technology, some firms double as out-patient clinics. For example, The Virtually Better virtual reality exposure therapy system originates from an outpatient clinic that uses the technology as well as other like therapies such as cognitive behavioral therapy and exposure therapy (Virtually Better Inc., 2013). Another non-scientific agenda being explored with VRET is that of the concern of the overall mental health of military personnel by the United States Department of Defense. In 2011, the Department of Defense gave researchers at Emory University School of Medicine, New York-Presbyterian/Weill Cornell Medical Center and University of Southern California an $11-million grant to conduct research on the two different types of exposure therapy, traditional and virtual reality, with a drug in order to treat PTSD. Another concern when applying virtual reality exposure therapy is the idea of "over-exposure" that can take place "in the name of science." Due to the relatively short time that virtual reality exposure therapy has been used and studied, it is very possible that researchers/therapists could choose to take advantage of patients in order to gain more insight regarding the efficacy of the therapy. Also, the therapist may choose to over-expose clients in order to determine exactly how much aversive stimuli an individual can withstand and still see progress.
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