CyberPsychology & Behavior Volume 1, Number 1, 1998 Mary Ann Liebert, Inc.

A Review of as a Psychotherapeutic Tool

BRENDA K. WIEDERHOLD, M.S., M.B.A.1 and MARK D. WIEDERHOLD, M.D., Ph.D.2

ABSTRACT

Simulations of reality have been used for over 30 years by the military for training and per- formance evaluations in a variety of tasks. Expensive and sophisticated systems today are used for training and certification of both commercial and military airline pilots. The inter- est in virtual reality by the entertainment industry has helped the emergence and develop- ment of low-cost virtual reality systems for use by the general public. Because of the unique nature of virtual environments, many investigators have begun to ask questions concerning the use of virtual environments for medical applications. Advanced simulators for surgical training are one example of a well-developed application using virtual reality techniques. In this article, we review the literature and explore the possibility of using virtual reality as a psychotherapeutic tool. Initial studies treating simple with virtual reality techniques are described. Issues relating to potential applications and possible side effects, as well as clinical outcomes and cost effectiveness, are also discussed.

VERY NATURE OF VIRTUAL REALITY Suggests use of virtual reality for the treatment of sim- THEa variety of interesting tools and ap- ple phobias.1-9 proaches that can be used to understand hu- Driven primarily by the entertainment in- man emotional response and the psyche. The dustry, low-cost virtual-reality simulators have ability to control an artificial environment and resulted in wide exposure of the general pop- then introduce a predetermined set of stimuli ulation to virtual worlds. Although some short- or challenges can in theory parallel the stan- term side effects such as "simulator sickness" dard model of office-based . The are being recognized, the long-term potential additional capabilities that are inherent in vir- effects are largely unknown.10-14 tual worlds can lead to greater creativity and In this article, we explore the results of ini- flexibility in the exploration and greater un- tial studies that have demonstrated both phys- derstanding of a patient's individual problems, ical and psychological effects secondary to ex- concerns, and underlying health-related issues. posure to simulated environments. Before Before this approach can be widely used, how- virtual reality can be widely used as a new ther- ever, several important issues must be ad- apeutic modality, any unforeseen or possible dressed, and a greater understanding of the ef- long-term negative effects must be factored in fects of virtual worlds on "normal" individuals to any decisions impacting on clinical use. must be determined. Nonetheless, several im- portant and interesting studies have already been completed that demonstrate successful VIRTUAL-REALITY TREATMENT OF ANXIETY DISORDERS Center for Advanced Multimedia Psychotherapy, CSPP Research and Service Foundation, San Diego, CA Simple phobias 92121. 2Department of Internal Medicine, Scripps Clinic Med- Several studies have been conducted using ical Group, La lolla, CA 92037. virtual-reality graded- (VR-

45 46 WIEDERHOLD AND WIEDERHOLD

GET) to treat simple phobias. These include ries of balconies with varying heights) were treatment of (fear of heights), fear used for the experiment. Subjects were given a of flying, fear of driving, and fear of spiders. screening questionnaire to ascertain whether Fear of heights. Recent full-immersion vir- they fit the criteria for a simple as de- tual-reality studies done with subjects who suf- scribed in the DSM-III-R. If they met the crite- fered from acrophobia have produced impres- ria, they were then given an acrophobia ques- sive results.1'6'7 Historically, behavioral tionnaire with scales measuring anxiety and treatment of acrophobia has included some avoidance. The questionnaire by Cohen has form of exposure-based therapy—either sys- been shown to discriminate between phobic tematic desensitization (whereby imaginai ex- and nonphobic persons. An attitude-toward- posure, i.e., the subject visualizes the feared heights questionnaire and a fear questionnaire height situations, and relaxation are combined) were also administered. During therapy ses- or in vivo exposure (where the subject is actu- sions, the SUDs were used. The subjects were ally exposed to real height situations). In that divided into two groups, one receiving the imaginai exposure has not been shown to work treatment just described and a wait-list control as well as in vivo exposure for the treatment of group. Both groups took the pretreatment as- acrophobia and in vivo exposure requires ac- sessment tests. The control group also took the tually leaving the therapist's office (running the same assessments 7 weeks later. The treatment risk of loss of confidentiality and leading to group received 35- to 45-min sessions weekly added cost and time for therapy), it was sug- for 7 weeks. Subjects were exposed to height gested that virtual reality might be a viable al- situations according to the hierarchy of dis- ternative, giving both the therapist and the pa- tressing height situations each subject com- tient more control over the graded-exposure pleted at pretreatment assessment. The thera- therapy and stimuli presented in the course of pist monitored each subject's exposure on a treatment. It was also proposed that virtual re- video monitor and could inquire as to how the would reduce the cost and time needed was while in the virtual envi- ality subject feeling for therapy. ronment. SUDs ratings were taken every 5 min In a case study using virtual treatment for during the therapy session to determine if the fear of heights, a subject was given an acro- virtual environment was actually evoking a phobia questionnaire to ascertain whether he feeling of presence in an actual height situation. met the Diagnostic and Statistical Manual of Men- At posttreatment, subjective ratings of fear, tal Disorders (3rd ed., rev.; DSM-IITR) criteria anxiety, and avoidance had decreased signifi- for acrophobia. He was also given a behavioral cantly for the treatment group but had re- avoidance test, pre- and posttreatment, and mained virtually unchanged for the control rated his subjective units of discomfort (SUDs) group. Some of those in the treatment group while ascending in a virtual glass elevator. even exposed themselves to real-world height Virtual-reality graded exposure was con- situations, even though they were not required ducted twice a week for 3 weeks (for a total of to do so. This seems to show that training in five sessions, each 35^15 min in length). The the virtual world does carry over to the real subject's scores at posttreatment showed a sig- world. Exposure therapy using a virtual envi- nificant reduction in anxiety, avoidance, and ronment provides a safe, confidential setting in distress. Obviously, because this is a case re- which to become desensitized to one's fears port, it lacks generalizability, but given the re- and phobias. Successful results occurred at a sults, it does lend itself to further investiga- much faster rate than with traditional exposure tion.7 therapy and desensitization.1'6 In today's envi- A controlled study involving 17 undergrad- ronment of managed care and cost-cutting uate students further supported the effective- measures, treatments that are reliable and also ness of virtual-reality therapy in the treatment more cost effective should attract significant in- of acrophobia. Three virtual height situations terest. (a glass elevator, a series of bridges with vary- These studies relied on the individual's sub- ing heights and degrees of stability, and a se- jective feelings of distress. It would be inter- VIRTUAL REALITY AS A PSYCHOTHERAPEUTIC TOOL 47 esting to begin quantitative, objective measures a conditioned response capable of being mod- of stress responses such as heart rate, blood ified. After initial therapy, several exposure pressure, or blood levels of epinephrine or Cor- sessions followed in which she viewed pho- tisol. The ability to obtain objective measure- tographs of spiders and plastic replicas of spi- ments in real time, correlated to the virtual-re- ders. Then the subject received twelve 50-min ality experience, would also give useful data on VRGET sessions, which included touching a psychophysiological aspects of therapy. replica of a spider while actually interacting . The Diagnostic and Statistical with a virtual spider. After completion of ther- Manual of Mental Disorders (4th ed.; DSM-IV) apy, the subject was able to go camping (an ac- classifies fear of flying as a , sit- tivity she had not done for 16 years due to her uational subtype, which is included in the fear of spiders), and she killed a spider found larger classification of anxiety disorders.15 The in her home (although not specifically in- DSM-IV lists lifetime prevalence rates for spe- structed by the researchers to do so).3 cific phobias as 10%—11.3%, with other surveys Fear of driving. A study to treat fear of dri- estimating that fear of flying exists in 10%-20% ving is currently being conducted by Berger of the population. Persons with fear of flying and his colleagues. This study will treat one as a specific phobia fear crashing, whereas group with VRGET and one group with con- those who develop fear of flying as part of ago- ventional exposure therapy.17 The lifetime raphobia fear having a panic attack while on prevalence rate for a Simple Phobia as reported an airplane.15'16 by the DSM-IV is between 10% and 11.3%. The There have been two case studies reported in lifetime prevalence rate for agoraphobia is be- the literature indicating that VRGET can be tween 1.5% and 3.5%. Because a fear of driving used as an alternative treatment for fear of fly- may be present alone as a specific phobia, or ing.2'4'5'8'9 In the first study, an individual who may be part of agoraphobic symptoms, this had become increasingly fearful of flying and treatment has the potential to help in the treat- had not flown at all for 2 due to her fear ment of a number of individuals.15 years large was first given seven sessions of anxiety man- and then six sessions agement techniques given OTHER ANXIETY DISORDERS of VRGET. The virtual-flight scenarios in- cluded a fixed-wing aircraft that performed a VRGET is also being explored for other anx- sequence of events including sitting at the run- iety disorders such as agoraphobia, social pho- way, taxiing, taking off, flying at altitude, and bia (with emphasis on fear of public speaking), landing. After completion of the VRGET, the posttraumatic stress disorder (PTSD), and ob- subject was able to complete an actual flight sessive-compulsive disorder. In those disor- with her family and reported less fear upon ex- ders where drug therapy is available, it would posure.2'8'9 be useful to consider a pharmacological arm of The second study involved an individual the study.5-18"20 who had previously received VRGET for his PTSD. Some 15% to 25% of survivors of fear of heights. The individual received five ex- traumatic events suffer symptoms associated posure sessions in a virtual helicopter, accom- with chronic PTSD.21 Of Vietnam veterans, panied by a virtual therapist. The subject's 450,000 (15%) meet the DSM-IV criteria for SUDs ratings decreased over the course of PTSD at 15 years post-Vietnam.22 Because of its treatment, indicating a reduction in fear. Long- varied symptomatology and resistance to treat- term follow-up is pending in this case report.4,5 ment, many treatment modalities have been in- Fear of spiders. Carlin, Hoffman, and vestigated. In a review of treatment modalities Weghorst conducted a case study to determine for PTSD, it was shown that most studies have the effectiveness of VRGET in the treatment of used some form of exposure therapy to treat fear of spiders.3 The subject treated had battled PTSD and that partial improvement has oc- a fear of spiders for 20 years. She was first given curred in most cases.21 therapy sessions to discuss the nature of her Virtual reality has also been investigated for anxiety and help reconceptualize her anxiety as use in those suffering from PTSD. Because ex- 48 WIEDERHOLD AND WIEDERHOLD posure-based therapy has been proven to work completion of a questionnaire. Subjects were with PTSD, by interspersing pleasant scenes in treated with eight 15-min sessions consisting of a virtual environment, one could more easily exposure to eight different virtual scenes: bal- provide the patient with a tool to work through conies, an empty room, a dark barn, a dark barn the trauma more slowly.18 with a black cat, a covered bridge, an elevator, In a 1983 study, Vietnam veterans suffering a canyon with a series of bridges, and a series from PTSD were compared to veterans not suf- of hot-air balloons at different heights. No at- fering from PTSD and to veterans suffering tempt was made to customize or individualize from other psychological disorders. The three scenes for each participant. After completion of groups were assessed on behavioral, physio- the VRGET, 24 subjects experienced a decrease logical, and self-report measures. It was found in both SUDs scores and scores on an agora- that the group suffering from PTSD differed phobia questionnaire. Because the specific fears from the other two groups when exposed to au- individuals may have can include diverse sub- diovisual stimuli of a combat nature but not ject matter, one can see the inherent advantage when exposed to a neutral audiovisual stimuli. and flexibility of using a virtual-reality world They displayed a greater increase in heart rate, for desensitization. It appears that VRGET may a greater avoidance response (wanting to ter- be useful in treating this disorder; however, minate the stimuli as evidenced by pressing a quantitative measures of physiology and long- button), and greater self-report levels of anxi- term follow-up should be used to help refine ety and fear than did the other two groups.23 future studies.5 By having physiological feedback available in the virtual world via noninvasive sensors, Social phobia the or could know computer therapist exactly In a a at Clark At- when to switch off the traumatic scene and preliminary report, group lanta has used virtual to treat avoid the too much distress. University reality causing patient with a fear of the must on the subjects public speaking. Subjects Currently therapist rely pa- were in front of a virtual audience and tient's (and the placed subjective feelings therapist's of the same as of these to the experienced many symptoms perception feelings) guide length do when in front of a real audience, of and subjects therapy exposure. such as a mouth, increased heart rate, and A headed and Rothbaum dry group by Hodges A SUDs scale and an Attitude has work on PTSD with vir- sweaty palms. just begun treating Toward Public were The will Speaking questionnaire tual-reality exposure therapy. study used to assess include Vietnam veterans at the Veteran's Ad- anxiety. Self-reported anxiety decreased after treatment.19 Studies are also ministration in Atlanta. Because of the Hospital the at Clark Atlanta Uni- varied suffered veterans underway by group symptoms by experi- versity to test the effectiveness of virtual real- PTSD, this will serve to stretch the encing study ity in the treatment of obsessive-compulsive limits of current virtual-reality technology.20 disorder.5 Agoraphobia. According to the DSM-IV, ago- raphobia involves "anxiety about being in or situations from which places escape might OTHER APPLICATION AREAS be difficult (or embarrassing) or in which help not be available in the event of an may having Eating disorders unexpected or situationally predisposed Panic Attack or panic-like symptoms." Because of In addition to work with anxiety disorders, this anxiety, the person with agoraphobia may work has been done in the application of vir- become avoidant of certain situations or will tual-reality technologies to other psychological endure those situations with much distress.15 disorders such as eating disorders, including In an interesting study, 30 undergraduate anorexia nervosa, bulimia nervosa, and obe- students with agoraphobia were treated with sity. VRGET. Inclusion in the study was based on The Virtual Environment for Body Image meeting minimum criteria of agoraphobia by Modification (VEBIM) is a system being devel- VIRTUAL REALITY AS A PSYCHOTHERAPEUTIC TOOL 49 oped in Italy by Riva and his associates to treat ment approach for this difficult clinical prob- body dissatisfaction and body-image distur- lem.26 bances that may be present in eating disorders. The two most commonly used methods of Social skills training treatment for eating disorders are cognitive- In a 1994 Muscott it behavioral and visuaomotor article by and Gifford, therapy therapy. to The VEBIM seeks to both was proposed that virtual reality be used en- system incorporate hance social skills for children and methods to offer a more effective treatment training sys- social skills tem. The system consists of a set of "zones" the youth.27 Currently training pro- involve such as behavior can after cer- grams techniques subject pass through performing and directive Al- tain tasks. Some zones give the the op- modeling teaching strategies. subject it is that skills are to "eat" and some zones that though recognized prosocial portunity require learned students involved in such the himself or herself before ex- by pro- subject weight it is also that be- iting to the next zone. The subject's real body grams, widely acknowledged is into the world, and haviors fail to transfer to natural environments, digitized virtual-reality such as the and com- the can view this while in the vir- playground, classroom, subject body It is that virtual would tual world and also create an image of his or munity. thought reality allow for more transfer of due to its her ideal using a system. Fi- learning body by morphing immersive that allows the user to ex- the must choose among various- quality nally, subject a sense of It would also al- sized doors, one of which corresponds to the perience presence. real size, before allowed low more flexibility in teaching social skills due subject's body being to such as to exit to the final zone. advantages visualization, multiple and active ca- The has been tested on a nonclinical users, scaling, problem-solving system test skills in the vir- of 71 to determine what effects pacity. Students could their sample subjects tual world to scenarios and the virtual-reality system would have on blood by reacting having the virtual world on their heart rate, and change depending pressure, body image. Subjects actions. This would teach the child how differ- were one 8- to 10-min ses- given virtual-reality ent behavioral choices result in different sion and were asked to pass different may through could allow a student's zones. Blood pressure and heart rate measure- consequences. Scaling size to be or made smaller to convince ments were taken before the virtual experience, enlarged him or her that be after treatment, and then again 10 fighting may unnecessary.27 immediately In a related access to advanced tech- min posttreatment. Prior to treatment, subjects article, such as television, video, and other were asked to experience scales nology complete body multimedia was offered as an for that seek information on the percep- explanation subjects' on standard intelli- tion of current body size and ideal size. After increasing improvement tests over the 50 to the session, scores gence past years. Contrary virtual-reality subjects' advanced and immer- showed a reduction in dissatisfaction and popular belief, possible body sive multimedia con- a smaller between ideal and actual technology may actually discrepancy fer an in body image. There was no significant change advantage learning.28 between blood pressure and heart rate mea- surements before treatment, immediately after treatment, or 10 min posttreatment.24 ADVANTAGES OF VIRTUAL Issues related to body image are very com- ENVIRONMENTS mon in the , with the prevalence for anorexia reported at 0.5% to 1%, bulimia at The virtual environment is very nonjudg- 1% to 3%, and obesity at 25% (34 million Amer- mental, and a person may find it much less icans).15,25 Although comprising the smallest threatening than the real world. Moving in the group, those suffering from anorexia have the direction of the "virtual therapist," a software worst prognosis, with 10%-20% progressing to program called the Therapeutic Learning Pro- severe morbidity or morality. Virtual-reality gram (TLP) was developed by Gould, a psy- therapy promises to offer an alternate treat- chiatrist at UCLA. It is a self-administered com- 50 WIEDERHOLD AND WIEDERHOLD puterized psychotherapy program that is com- increased risk to adverse events in virtual sys- pleted in 10 sessions. One recent study divided tems. 100 patients with depression and anxiety into In light of the recent debate over "implanted a treatment group (TLP) and a control group memories," the possibility that a virtual expe- using random assignment procedures. Pre- and rience may become ingrained in one's memory posttreatment measures were performed to as- and be indistinguishable from a real experience certain severity of depression and anxiety. is possible. During exposure therapy to desen- The study found that both groups had sig- sitize an individual who has been traumatized, nificant improvement at the end of treatment care must be taken to avoid adding additional and at a 6-month follow-up evaluation. The traumatic memories.3 Others who may be at TLP group was given the new computer-gen- risk are drug abusers or others with addictive erated 10-session treatment and included a 10- personalities, those with various other mental to 15-min interaction after each session with a illnesses, and those who are emotionally un- therapist to clarify information and answer stable.30 questions. Therapeutic conversations were In a virtual world, there is deliberate manip- strictly avoided. The control group was given ulation of a person's senses and the possibility 10 hr of standard therapy (10 sessions) with a for disembodiment, gender swapping, multiple psychologist. identities, and parallel communications. If In that both groups demonstrated similar someone were dissatisified with their current re- improvement at follow-up, the use of com- ality, they may prefer this new virtual reality to puter-generated programs may augment the real life, causing social alienation and loneli- standard practice of psychotherapy. This study ness.30 As technology continues to improve, the has helped to fuel speculation of delivery of quality and believability of virtual worlds will psychological services over the Internet. Low- continue to increase. Could the virtual world be- cost interactive video including use of a cus- come indistinguishable from the real world? If tomized "video therapy room" may have fu- this were the case, there would be no distinction ture application in the delivery of mental health between fantasy and reality. The consequences services. The ability to utilize a therapist's time of this situation are unknown at this time but more effectively could improve efficiency and raise significant questions for discussion. reduce costs. Reducing the cost of psychother- The risk of becoming more socially isolated apy would help to make it available to a wider also is possible with virtual reality. Will our range of patients.29 sense of community and neighborhood dimin- ish? Without direct human interaction, will rudeness, violence, or other negative conse- PRECAUTIONS OF VIRTUAL quences occur? If we are able to have virtual ENVIRONMENT USE sex, interact with other persons in cyberspace, and use our modem to communicate with our Virtual-reality techniques may not be ap- office, will normal societal interaction as we plicable to all psychological disorders or to all known it cease? These are interesting questions patients. It has been suggested that because that can provoke discussion and further inves- schizophrenics suffer from a detachment from tigation.31 In addition, a variety of physical reality, placing them in virtual worlds for ther- problems can occur in virtual environments. apy, then exposing them back to reality, could These problems include simulator sickness, actually increase their level of confusion.30 For eyestrain, flashbacks, tendonitis, and possible those who suffer from claustrophobia, the con- addiction.10"14-32"34 finement of a head-mounted display may ac- tually increase their symptoms. Those who suf- fer from agoraphobia may experience anxiety CONCLUSION at viewing a virtual world with infinite hori- zons. Prescreening of patients may be neces- Virtual-reality techniques will provide many sary to determine those individuals who are at novel avenues for the evaluation and treatment VIRTUAL REALITY AS A PSYCHOTHERAPEUTIC TOOL 51 of psychological conditions. Several studies 3. Carlin, A.S., Hoffman, H.G., & Weghorst, S. (1997). have already shown benefit in the treatment of Virtual reality and tactile augmentation in the treat- This in ment of spider phobia: A case report. Behavioral Re- simple phobias. improvement symp- search 35(2), 153-158. toms was to exist 6 Therapy, shown months posttreat- 4. North, M.M., North, S.M., & Coble, J.R. (1996). Vir- ment.6 It is clear, however, that some issues and tual environments psychotherapy: A case study of concerns must be addressed before widespread fear of flying disorder. Presence, 6(1), 127-132. implementation of virtual therapy becomes 5. North, M.M., North, S.M., & Coble, J.R. (1996). Vir- It is not clear, for that tual reality therapy. Colorado Springs: IPI Press. commonplace. example, 6. Rothbaum, B.O., L.F., Kooper, R., all individuals will be able to relate or function Hodges, Opdyke, D., Williford, J.S., & North, M. (1995). Effectiveness of in a environment. Because virtual the virtual computer-generated (virtual reality) graded exposure world is so enveloping, it is not clear how to in the treatment of acrophobia. American Journal of provide patients with a predictable means of Psychiatry, 152, 626-628. 7. escape or some other in which Rothbaum, B.O, Hodges, L.F., Kooper, R., Opdyke, methodology D., Williford, North, M. (1995). Virtual the can maintain control of the session J.S., reality patient in the treatment of A and environment. could how- graded exposure acrophobia: (One always, case report. Behavior Therapy, 26, 547-554. ever, remove the headset.) 8. Rothbaum, B.O., Hodges, L., Watson, B.A., Kessler, An interesting approach is provided by the G.D., & Opdyke, D. (1996). Virtual reality exposure Virtual I/O multimedia company. In this vir- therapy in the treatment of fear of flying: A Case re- tual world, if the looks to the far port. Behavioral Research Therapy, 34(5/6), 477-481. patient right 9. 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