Ryan Howes

Ryan Howes PhD, ABPP

In Therapy

Cool Intervention #2: Virtual Reality

10CTI: Psychotherapy finally plugs in

Posted Feb 09, 2010

Get ready for Avatar-meets-Xbox-meets-Freud's-couch as techies like USC's Skip Rizzo usher psychotherapy out of the 1980s and into the information age. Just in time to become one of the Ten Coolest Therapy Interventions.

When it comes to technology, psychotherapy has woefully trailed the other sciences. Biology, physics, chemistry, engineering and other "hard sciences" pounced on each technological advance to squeeze every last kilobyte of data from the research. For years their supercomputers thundered away while psychology gingerly tapped at a Commodore 64. Geophysicists studied paleomagnetism using an arsenal of techno-gagetry and we hand-scored Rorschachs with our trusty slide rule and abacus. In a field that takes pride in its progressive thinking, psychology was largely comprised of Luddites. Until now.

The days of undergrads dodging their science requirement by hiding in the psych department are numbered.

Today I speak with Dr. Skip Rizzo, Associate Director of the Institute for Creative Technologies at the University of Southern California, where he oversees the design, development and evaluation of Virtual Reality (VR) systems targeting the areas of clinical assessment, treatment and rehabilitation. His work with VR helps treat PTSD in Iraq vets, strengthens memory in Alzheimer's patients, helps hospitalized children manage their pain and clinicians hone their interviewing skills. Basically creating the world's best video games to help people and society. When he's not playing rugby or listening to Captain Beyond, Dr. Rizzo dons his lab coat and propeller beanie and does some incredible work. Take a look:

1. When would a clinician use Virtual Reality?

The thoughtful and informed use of VR simulation technology requires a clinician to understand the actual "assets" that VR "tools" bring to the clinical table and how these digital assets match up to the needs of a specific therapeutic strategy. Our lab at USC has investigated Clinical VR design, development and evaluation since 1995 and have found "added-value" with VR applications for: 1) prolonged exposure therapy for anxiety disorders and PTSD; 2) neuropsychological assessment and rehabilitation conducted within highly controllable VR simulations of 3D content (visuospatial ability tests) and functional everyday environments (e.g., schoolrooms, offices, homes, etc.); 3) motivating physical and occupational therapy in persons with sensorimotor impairments due to CNS dysfunction and other disease processes by creating VR Game-based applications that patients can interact with to practice 3D motor skills within activities that allow for precise stimulus delivery and motor response capture relevant to their specific rehabilitation needs; 4) distracting patients from painful medical procedures to reduce pain perception and discomfort while immersed within a VR Game; 5) the creation of artificially intelligent (AI) virtual patients (with voice recognition) that allow novice clinicians to practice both diagnostic and therapeutic interviewing skills with a range of challenging virtual clinical populations (e.g., resistant clients, sexual assault, PTSD exposure therapy, etc.).

2. What does it look like?

Depending on the therapeutic and/or research target, Clinical VR simulations vary. On a basic level, they can consist of stereoscopic 3D stimuli that support complex user interaction with relevant visuospatial content (e.g., mental rotation, depth perception, maze learning, etc.). While on a more complex level, clinicians have created virtual airplanes, skyscrapers, automobile driving worlds, Vietnam/Iraq/Afghanistan battlefields and the everyday functional worlds of the home, office, market and classroom. One of the more common approaches to delivering a VR environment to a patient is to outfit them with a head-mounted display. Head-mounted displays consist of a set of "goggles" with separate display screens for each eye, and with the aid of a head-tracking device, the user is immersed within a computer-generated view of a virtual world that changes in a natural way with head and body motion. However, VR worlds can also be usefully presented to clients via a basic computer monitor or floor-to-ceiling stereo-projected walls or rooms. More recently, with advances in AI, voice recognition, computer processing power and graphics technology, it has now become possible to "populate" virtual worlds with virtual humans that a "real" person can interact with. This opens up new possibilities for Clinical VR applications for training, psychosocial interaction, and learning.

3. How does it help the client?

Within very controllable VR simulations, the potential now exists for the clinician to bring relevant digital representations of the outside world into the therapy office depending on the clinical purpose. Within this "Ultimate Skinner Box", patients can be gradually (and safely) exposed to feared content at a pace they can handle, can be tested or trained under a dynamic range of stimulus conditions, can be distracted from painful medical procedures while being immersed within a VR Game, and can practice social interaction in a variety of contexts under varying levels of support. However, it is important to recognize that VR is simply a tool. The real power of any therapeutic intervention lies in the hands of a well-trained clinician! Thus, VR gives the therapist a very sophisticated tool for creating therapeutically informed virtual situations that extend both the clinician's skills and the patient's experience. However, we certainly do not advocate the creation of automated VR diagnostic or treatment approaches that purport to be a substitute for a clinician with expertise in a specific area of clinical practice ("Doc in a Box" approach). In most cases where independent and/or remote use of VR simulation tools by patients has been proposed, it has typically been in the context of its use as an adjunctive tool for clinical homework (supervised by a clinician), or within a teletherapy approach with the clinician having some cyber-connection to the patient within well-specified ethical guidelines.

4. In your opinion, what makes Virtual Reality a cool intervention?

There is no doubt that VR has a "coolness" factor that attracts popular media interest in the various ways that it is applied. However, it is also one of those rare technologies that are both cool and logically justified. Since the beginning of the "psychology as a science" era, researchers and clinicians have recognized the value of systematically controlling a stimulus environment and measuring or modifying behavior within that context (or experimental condition). VR technology appears on the scene at a time when great advances have occurred in the domains of response measurement (e.g. computerized psychophysiological assessment, brain imaging, and even database mining tools needed to compile "sense" from massive amounts of response data!). VR now stands to balance out the stimulus-response equation, by providing options for the creation of sophisticated, dynamic and controllable stimulus environments (whether for precise research or clinical care) that were not pragmatically possible prior to its advent. So, while this stuff is damn cool, it also makes a lot of sense when applied thoughtfully. I will go so far as to say that we are at the start of a revolution in clinical research and care, in large part due to the game-changing impact that VR and other related digital technologies will have, as we charge ahead into the 21st Century! And, what the hell, it's about time that clinicians, long deprived of such novel excitement, had a few cool toys to play with!

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