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VR Series #3 Psychological Therapies

06 April 2018
Ian Slater discusses the use of VR to treat disorders, such as PTSD, by allowing clinicians to carefully control a patient's level of exposure to stimuli.


In broad terms the biggest application to-date has been to facilitate exposure therapy in the treatment of anxiety disorders. Exposure therapy itself is a form of individual psychotherapy based on Foa and Kozak’s (1986) emotional processing theory, which states that [for example] PTSD involves pathological fear structures (that include the emotional memories of the traumatic experiences) that are activated when information represented in the structures is encountered. Successful treatment requires emotional processing of the fear structures in order to modify their pathological elements so that the stimuli no longer invokes fear or anxiety.

To give an example, if someone is afraid of flying you could:

  1. talk to them and see how they react;
  2. show them videos; or
  3. take them to an airport

The three options gradually rise through the intensity scale.

The problem, however, is that if the clinician is not far enough along the scale (perhaps just having a conversation) there is no reaction to measure or treat, and if you go too far (actually putting the patient on a plane) then the he/she can become overwhelmed.

VR allows the clinician to carefully control the level of exposure: increasing slowly but surely over time. If combined with fMRI the clinician can actually see how the patient's brain is reacting to any given level of stimulus. What I still find amazing is that exposure therapy using VR is just as effective as taking the patient into the real live situation.

We don't, however, stop with anxiety disorders: evidence is also growing for VR’s potential to assist in the treatment of PTSD in conjunction with other treatments and therapies. Among the many approaches that have been used CBT with exposure therapy appears to have the best-documented therapeutic effectiveness (Bryant, 2005; Rothbaum, Meadows, Resick, et al., 2000; Rothbaum, Hodges, Ready, Graap & Alarcon, 2001; Rothbaum & Schwartz, 2002; Van Etten & Taylor, 1998).

In 2004, the University of Southern California’s Institute for Creative Technologies partnered on a project funded by the Office of Naval Research to develop a series of VR exposure therapy (VRET) environments the first of which was known at the time as Virtual Iraq.

Remember that the aim is for people in the simulation to narrate their own personal experience in the first person whilst immersed in the VR environment. Most users report that the VR environment has hit a good balance: the environment doesn't need to be completely realistic but, rather, sufficiently so in order to provoke the emotional memories.

Correcting for the PCL-M no-symptom baseline of 17 indicated a 50% decrease in symptoms and 16 of the 20 completers no longer met PCL-M criteria for PTSD at post treatment.

Using accepted diagnostic measures, 80% of the patients in the initial VRET sample showed both statistically and clinically meaningful reductions in PTSD, anxiety and depression symptoms. Anecdotal evidence from patient reports suggested that they saw improvements in their everyday life situations which were maintained at three-month post-treatment follow-up.

Initial results look impressive but more work is required. Much of the leading research in this area has been conducted by Dr Albert 'Skip' Rizzo who, in 2016, published a paper Virtual Reality Exposure for PTSD due to Military Combat and Terrorist Attacks [Rizzo et al. J Contemp Psychother DOI 10.1007/s10879-015-9306-3].

The paper looks to evaluate the effectiveness of Virtual Iraq/Afghanistan together with Virtual World Trade Center (developed for the treatment of 9/11 survivors). It concludes that clinicians like VR as:

  1. it delivers an environment which is consistent, controllable and immersive trauma-relevant;
  2. it provides an objective and consistent format for recording the stimuli that the patient is exposed to thereby allowing the relevant stimuli to be precisely linked to physiological and self reported reactions;
  3. it improves treatment appeal and acceptability particularly for younger generations.

The authors conclude, however, that despite the initial positive results further randomized controlled trials are required to understand such things as the precise elements of VRET which are crucial to distinguish it from standard CBT approaches and the demography of the patient who will benefit most from it.

Notwithstanding such [research] caution one commercial company seems to be pressing ahead with a subscription based service for the home treatment of such disorders as anxiety, depression and stress. They currently have a call out for beta testers with an anticipated rollout of their platform in the 4th quarter of 2018… it remains to be seen whether that particular example is a step too far too soon but as a sign of things to come?

Interesting times…

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Further Reading