Feature

or many clinicians, the thought of using video games, Second Life, virtual reality and other cybertechnology to treat clients might seem as unfamiliar as applying acupuncture needles or prescribing homeopathic remedies. But new research is demonstrating that these technologies do enhance the effectiveness of clinical work, at least in some domains.

Some research has shown, for example, that young war veterans with PTSD are more amenable to a "techie" treatment approach than to traditional therapeutic approaches. Also, virtual reality techniques can sometimes be more practical than live treatments for helping patients overcome fear of flying or fear of heights, for example.

The work is not just jumping on the latest high-tech bandwagon. Rather it's applying a new method to address traditionally hard-to-treat conditions, says psychologist and therapeutic virtual reality pioneer Albert "Skip" Rizzo, PhD, who co-directs the VRPSYCH Lab at the Institute for Creative Technologies at the University of Southern California (USC).

In fact, recent data suggest that some of these high-tech treatments may work better than the available alternatives. A meta-analysis of 13 studies by Mark B. Powers, PhD, and Paul M.G. Emmelkamp, PhD, reported in the April Journal of Anxiety Disorders (Vol. 22, No. 3), for example, found that virtual reality exposure was more effective than imaginal exposure and at least as effective as in vivo exposure in treating a range of anxiety disorders—including a variety of specific phobias, social phobia, PTSD and panic disorder—as well as their overall symptomatology. (All types of exposure therapy are grounded in principles of classical conditioning.)

In addition, a meta-analysis of 22 studies on anxiety disorders and phobias, recently published in the Journal of Experimental Psychiatry and Behavior (Vol. 39, No. 3), found large declines in anxiety symptoms following virtual reality exposure therapy, in some cases compared with other treatments, and in other cases when there was no control group. Again, the analysis looked at a wide range of conditions and their symptoms, including PTSD, social phobia, agoraphobia, and specific phobias such as fear of flying.

A few factors may help explain why virtual reality exposure therapy may be more effective than other treatments, Rizzo says. For one thing, exposure therapy itself—whether in vivo, imaginal or virtual—has been shown to be more effective than other treatments such as psychotherapy or psychopharmacology because of its behavioral-science base of activating a person's fear structure, then presenting incompatible information showing that the world is a safe place, which in turn leads to a reconditioning of the original frightening stimulus. Virtual reality adds to the strength of exposure treatment by immersing people in a realistic version of the fear stimulus rather than having them imagine it, which can be fraught with problems including the vagaries of imagination and avoidance, Rizzo says. (Imaginal exposure can be especially problematic for people with PTSD, he adds, because imagining the original trauma can be so aversive.)

So in effect, the virtual environment removes the need for the client to exclusively rely on imagination, he notes. And it's easier than in vivo treatment since it is available right in the clinician's office, he adds.

That said, such interventions are designed to augment, rather than to replace, standard treatment, Rizzo emphasizes.

"Technology by itself does not fix anybody," he says. "Rather, it helps to support the patient in the hands of an expert clinician, allowing him or her to leverage these tools to make the most of an already effective treatment."

'Virtual Iraq'

In one project that's received recent media attention, Rizzo and colleagues JoAnne Difede, PhD, of Weill Cornell Medical College, and Barbara Rothbaum, PhD, of Emory University, developed a virtual environment—dubbed "Virtual Iraq"—that helps war veterans process their trauma by immersing them in a virtual, sensaround world resembling that of wartime Iraq. (The Virtual Iraq product is available online.)

Before the client enters the virtual world, he meets three times with a therapist to establish a bond of trust. Then, with the guidance and support of the therapist by his side, the client dons virtual reality goggles and earphones and receives eight sessions of exposure therapy in a virtual Iraqi city, complete with the sounds of gunfire and explosions and the sights of people in the streets. Meanwhile, a scent machine conjures up smells related to the scene, including the aromas of Middle Eastern spices and other less pleasant scents like the smells of burning rubber and rotting garbage.

In the initial sessions of therapy, the client recounts his traumatic experiences to the therapist and discusses his readiness to deal with them. When the client is ready, the therapist recreates the client's reported traumatic experiences in the Virtual Iraq environment—for example, watching a comrade get hit by a grenade—bringing up the sights, sounds, smells and other sensations associated with the event. Over more sessions, the client continues to work with the therapist to recount and experience the trauma until it no longer holds him in its grip.

"As one soldier put it, 'The war will never leave me, but now I know I can handle it,'" Rizzo says.

So far, the treatment appears to be working. In a chapter in the upcoming book The Neurobiology of PTSD (Humana Press, 2008), edited by Priyattam Shiromani, PhD, Terence M. Keane, PhD, and Joseph E. LeDoux, PhD, Rizzo and colleagues report that 12 of 15 people who participated in 12 weeks of treatment no longer met PTSD criteria. The intervention is about to undergo a more rigorous test as well: In a trial funded by the Department of Defense, psychologist Army Capt. Greg Reger, PhD, Rizzo and colleagues will compare the treatment with imaginal exposure, the current treatment of choice for war-based PTSD.

SnowWorld for soldiers

In a related line of work, cognitive psychologist Hunter Hoffman, PhD, of the University of Washington's Human Interface Technology Laboratory, and colleagues are testing virtual reality's application to Iraq War soldiers who have been seriously burned.

The work draws on a decade of research by Hoffman and University of Washington rehabilitation psychologist David R. Patterson, PhD, using virtual reality, as well as Patterson's research using hypnosis for pain. They designed a virtual reality treatment specifically for burn patients called SnowWorld, which distracts young civilian burn patients from the pain of treatment (see www.vrpain.com). With slight head movements, users can traverse a beautiful icy world, and with mouse clicks or taps on a computer space bar, they can play a virtual snowball game with snowmen, penguins and woolly mammoths to the rhythmic music of Paul Simon.

In his new research with Christopher Maani, MD, of the U.S. Army Institute of Surgical Research, Hoffman has added a new component to SnowWorld: Because these soldiers are so seriously injured, Hoffman has devised a robotic arm that holds lightweight goggles in place near the patient's face so they don't have to wear a helmet.

The researchers conducted a pilot test of the intervention by treating two burn victims—both soldiers seriously injured in the Iraq war—with and without SnowWorld. As reported in the Journal of Cybertherapy and Rehabilitation (Vol. 1, No. 2), both men exhibited large reductions in their sensations of pain and in the time they thought about the pain, and rated their wound care as more "fun," during the virtual reality pain distraction.

A more pleasant recovery

Researchers are applying these tools to peacetime uses as well. Rizzo, for instance, has spent years developing virtual game-based interventions that help people recover from brain injury and stroke, making a painstakingly slow rehab process easier and more fun.

"We can put an interface on a person's wrist, arm or leg, for example, and whatever movement the person is able to make translates into a meaningful action in the virtual world," he says.

With a tiny range of motion, a client can fly an airplane through a canyon, zip a rocket through an asteroid belt or slide a penguin on its belly down a ski slope—all providing an entertaining incentive to keep working on problems involving motor movements and balance. The U.S. Army is now funding work to refine and extend those programs.

Rizzo has also developed an instrument to assess ADHD by observing aspects of a child's attention and movement in a virtual classroom. And in work funded by the National Institutes of Health, the team is designing virtual reality prototypes for cognitive assessment that will be part of a comprehensive "toolbox" of standardized, state-of-the-art psychological assessment instruments, Rizzo says.

But because the area is still young, many questions arise: Is therapeutic virtual technology a gimmick that will fade over time? Can it be provided cost-effectively so more people can reap its benefits?

While these questions are up for discussion, the technology has become a part of our human landscape—so much so that it's improving continuously and new applications keep suggesting themselves.

As such, Rizzo encourages his clinical colleagues to keep their minds open to new technology.

"That's the focus of our lab—to help psychologists understand better and use these 21st-century tools in their practice."


Tori DeAngelis is a writer in Syracuse, N.Y.