Exposure Therapy In A Virtual Realm

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Virtual reality (VR) displays like the Oculus Rift mount over the eyes and allow the user to delve completely into the world of a fictional game or movie. But what if you could strap on the VR goggles and re-experience the past, perhaps to even confront your worst fears and memories?

For researchers like Dr. Skip Rizzo and Dr. Barbara Rothbaum, these gadgets represent a technological doorway into new possibilities for therapy treatment that decades of research have been eagerly awaiting.

According to Rizzo, professor and director of Medical Virtual Reality at the University of Southern California’s Institute for Creative Technologies, he began researching the therapeutic benefits surrounding VR for brain injury patients in the early 1990s.

“They [medical researchers] were seduced by the vision, and I was as well.,” Rizzo tells BTRtoday. “It was a very sound vision, the idea of putting people in highly controllable situations where you could test, train, teach, or treat their functioning. It made a lot of sense.”

Traditional exposure therapy involves a patient recreating a scenario that incites fear, anxiety, or stress. Therapists ask patients to recount memories of trauma or fear out loud to be recorded and listened to later on. The use of VR would expand the auditory exposure by introducing a visual representation to the patient that otherwise was left to imagination.

Rothbaum, a professor of psychiatry and director of the Healthcare Veterans Program & Trauma and Anxiety Recovery Program at the Emory University School of Medicine, also studied the therapeutic effects of VR in the early ‘90s. She’s an author on the original patent for using VR to treat a psychological or psychiatric disorder, and conducted the first study in that vein, looking at how it might help individuals with acrophobia, or fear of heights.

“It wasn’t that we thought we needed a new treatment for the fear of heights, but it was like a test balloon for whether or not VR exposure therapy would work,” Rothbaum tells BTRtoday. “It did, and it worked really well. Some of our conclusions from that first study were that feelings or behavior in the natural world actually could be influenced by experiences in the virtual world.”

Rothbaum also found that VR had a positive effect for treating PTSD in former combat veterans. For her study, developers created a virtual Vietnam, and exposed patients to situations that brought about the most stress. VR’s immersive nature forced PTSD patients to confront their trauma more directly than traditional exposure therapy.

“Part of what we’re exposing them to is the memory of their trauma,” Rothbaum says. “In general, folks are very avoidant. They don’t want to think about it or go there. So what we do is go there on purpose.”

It’s a technique that hopes to tackle distressing memories for patients and help them experience the real life situations that trigger those traumatic memories, continues Rothbaum.

Though clinical benefits displayed throughout the 1990s were obvious, it soon became clear that the technology wasn’t quite advanced enough to deliver on its expectations. Rizzo describes the mid-to-late ‘90s as a kind of “nuclear winter” of virtual reality, when many of its original proponents gave up on it. Rizzo, Rothbaum, and others were some of the few that continued their research, and eventually the technology caught up.

“Computers got faster; novel and interesting interface devices were developed; graphics definitely improved,” Rizzo says. “These things all pointed the way toward the idea that the technology is ready now. For people in my field, developing VR applications for clinical purposes, the technology is more than sufficient to really do some dramatic things.”

That’s where the Oculus, Vive, and other new virtual reality displays come into play. With such tools available on the consumer market, the accessibility to VR exposure therapy should increase in coming years due to decreasing costs.

There are other technical factors, such as criticisms surrounding cyber sickness and overall clinician willingness, that stand in the way of VR therapy development. Additionally, there are doubts about patients relying more on digital technology and less on the value of human-based therapy.

“I think the technology can amplify the impact of a clinician without minimizing the therapeutic relationship,” Rizzo posits. “In some sense, the patient might feel a deep connection with the clinician, because at least the clinician has seen something that resembles what the patient was traumatized by, not just a description of it. It’s more of a shared experience.”

Research in VR exposure therapy is ongoing, but now the focus has changed a bit. The question is no longer whether or not the therapy is effective, but rather what treatment is most effective. Rothbaum conducted studies comparing VR and traditional exposure therapy to patients with flight phobia and found that VR exposure therapy worked just as well. There is also the convenience of creating the controlled simulations of takeoffs and turbulence for the therapy.

Both Rothbaum and Rizzo are now involved in a large clinical trial study supported by the Department of Defense that compares traditional prolonged exposure therapy for PTSD veterans with VR exposure therapy, both with and without D-Cycloserine, a drug shown to facilitate the extinction of fear. While the results of that study won’t be available for some time, they are a step in the direction of figuring out the effectiveness of both therapies and how they apply to individual patients.

“I’m certainly not an advocate that we need to virtualize everything and that should be the only form of treatment,” Rizzo says. “I don’t think it’s a one size fits all. I think our goal in these areas is to create a range of treatment options and find out what the best treatment is for the person’s individual needs.”

As the concentration of research and conversation shift from its overall effectiveness to individual application and access, it seems clear that VR exposure therapy’s time has come.

“In general, people say that it takes about 20 years from the time a study is published to get into real use,” says Rothbaum, whose initial study on acrophobia was published in 1995. “That’s about where we’re at.”