Cover Story

For 30 years, New York psychologist Richard H. Wexler, PhD, has helped companies develop effective leaders and productive teams. But in the last three years, much of his work has taken place not in Manhattan office buildings, but in virtual meeting rooms. There, digital versions of employers and employees, or avatars, come together to work on projects, get training and receive help with professional or personal problems.

"Until recently, the technology just wasn't available for the average practitioner to be able to do this sort of thing," says Wexler. "But it's moving so rapidly that [now] you're limited only by your imagination."

Wexler and his wife, psychologist and executive coach Suzanne Roff-Wexler, PhD, are part of an emerging cadre of psychological practitioners, researchers, trainers and product developers who are bringing avatars and other forms of virtual technology into the practice realm.

"I wouldn't want to make the case that these technologies are the be-all and end-all, or that they're going to replace face-to-face psychotherapy," says clinical researcher James Herbert, PhD, a Drexel University psychology professor, who has studied avatar therapy. "But they are tools that really do have some advantages."

These virtual environments are computer-simulated interactive spaces that appear and feel to users like they're inhabiting a relatively real setting. They are often populated by avatars that interact, talk, gesture, walk and "teleport"—travel to any location they choose. Virtual environments create a feeling of person-to-person presence and immersion—the sense of actually sharing a space with others, Wexler says.

Psychologists are using two types of virtual technology in therapy, teaching and training, and organizational consulting. One technology is immersive virtual reality, sometimes called "classic" immersive virtual reality. In classic immersive settings, people don goggles and headphones and are transported into a three-dimensional world that can include highly realistic sights and sounds, as well as smells generated by computer-controlled scent machines. The second is flat-screen technology, through which you can access computer-generated three-dimensional environments on your computer or television screen. A well-known example is Linden Labs's Second Life, a "metaverse" that allows anyone to log in for free, adopt an avatar and roam unencumbered through a cyberspace filled with restaurants, college campuses, business settings and a variety of fantasylands.

Practitioners use these technologies in different ways and with greater or lesser ease, says neuroscientist Walter Greenleaf, PhD, chief strategy officer at Thrive Research, a research and development company that licenses a behavioral wellness platform. Immersive virtual reality is generally done in the same room as clients, and tends to be easier for both clients and clinicians than Second Life-type settings because it's more controlled and has a smaller learning curve. (In Second Life, for example, you have to learn to dress yourself, navigate and communicate in new ways.)

That said, the two technologies are useful for different purposes and conditions, he says. "In general, if a treatment involves social skills and other aspects of interpersonal interaction—how to deal with a mean boss, for example—clinicians feel comfortable conducting therapy over the Internet using avatars," he says.

That's also the case with student training or business applications. But if it involves post-traumatic stress disorder, anxiety disorders or other stressful situations, clinicians like to use classic immersive virtual reality tools and to stay in the room with the patient so they can help manage difficult symptoms as they arise, Greenleaf adds.

Virtual reality therapy

Key features of classic immersive virtual reality are its ability to augment people's senses and imaginations, says Ivana Steigman, MD, PhD, also of Thrive Research. In the area of substance abuse treatment and recovery, for instance, Steigman is working on an application that brings patients into scenes resembling those that fuel their addiction—bar settings, for example—or of emotional triggers, such as family conflicts. By bringing these scenes directly to the client and therapist, clients can bypass a big problem in traditional therapy: having to visualize and recall scenes accurately, Steigman says.

In turn, this versimilitude provokes the same emotions that would be stirred up in real life. "After a while, when you put a [virtual] beer or line of cocaine in front of someone, the person is sweating," she says. "So you can really mimic their emotional turmoil."

The experience enables clients to experience emotions in a controlled way, to practice refusal skills and to gain confidence within a given situation. For example, the therapist may stop a loaded scene at a key moment so the two can talk about it, or repeat it until the client has learned how to change his or her reaction to it.

Other clinicians are using these technologies to treat people with phobias, post-traumatic stress disorder, social anxiety disorder and autism spectrum disorders. Georgia psychologist David E. Stone, PhD, launched WorldWired, a company that makes tailored virtual environments for clinicians. He uses the technology to treat veterans with PTSD using a virtual immersive form of prolonged exposure therapy, developed with his colleague Deborah Patton. "I have precise control over what is going on," says Stone. "I can change the images, sounds and smells according to the patient's experience. I can take the scenario forward or backward."

Flat-screen apps

Psychologists are using flat-screen avatar technology in a variety of ways as well. In their own virtual world, Wexler and Roff-Wexler work with power and design companies to provide organizational, management and team training. To develop leadership skills, for instance, a potential leader is placed in a virtual world with an avatar "employee." The leader is told he must get the employee to accomplish the task of putting puzzle pieces together to form a box. At some point the avatar knocks all of the pieces down rather than completing the puzzle. The action becomes the basis of training people how to work with employees when they make mistakes—motivating them to complete the puzzle, for instance, rather than doing it for them.

Meanwhile, Cynthia Tandy, PhD, of Valdosta State University, uses Second Life to supplement her monthly face-to-face training with students. To help them practice counseling and interviewing skills, she has created a simulated social service agency in Second Life featuring rooms that resemble settings they may eventually work in—say a hospital room, a jail cell or a home setting. The students practice evaluating virtual prisoners and counseling virtual hospital patients. They also do group projects online.

The medium goes a long way in sustaining their interest, Tandy is finding. "They'll say to me, ‘I feel like I was there, I feel like I was in that environment, it was so much better than being in a classroom,'" she says.

Other psychologists are conducting therapy in these environments. As part of a pilot study, Herbert and his students treated patients with social anxiety disorder in a secure therapy room on Second Life. The use of avatars, he says, proved a real boon for role-playing, a key element in social-anxiety treatment used to help patients learn social skills, test and refute cognitive distortions about social interactions, and experience controlled anxiety in the face of social situations. "With Second Life, you can create avatars of different ages and genders, greater or lesser attractiveness—whatever is called for," he says.

The technology has other distinct advantages for treating patients as well, Herbert adds. Clients can log on anywhere, so people who have difficulty making it into the office can easily have sessions or short booster sessions from home or on the road. And he is particularly keen on the technology's ability to bring treatments to those who wouldn't otherwise have access.

Promising early findings

Preliminary research suggests that these interventions work. A study by psychologist Greg M. Reger, PhD, and colleagues in the February 2011 issue of the Journal of Traumatic Stress, for instance, finds that active-duty soldiers who undergo an immersive virtual form of prolonged exposure therapy have a significant reduction in post-traumatic stress symptoms by the end of treatment. Three randomized controlled trials comparing that treatment with more traditional treatments are now under way. Meanwhile, a yet-unpublished pilot study by Herbert and Drexel colleagues Evan Forman, PhD, Erica Yuen and Elizabeth Goetter finds that clients with social anxiety disorder who adopted avatars and were treated in Second Life using evidence-based cognitive behavioral therapy showed as much improvement as clients they saw face-to-face.

Other research indicates that some people stick with virtual treatment longer. In an ongoing study of teens with substance abuse problems funded by the Missouri Foundation for Health, Dick Dillon, of the nonprofit behavioral health-care company Preferred Family Healthcare, is finding that young people who receive treatment in a secure, Second Life-type environment are more than twice as likely stay in treatment as those in traditional treatment. They also attend two-and-a-half times more therapeutic activities than controls.

Questions remain

Still, it remains unproven whether these virtual modalities are any better as platforms for treating people than other distance therapies such as Skype, phone or emailing. Herbert, for instance, has conducted a pilot study showing that Skype produced even bigger effect sizes in helping people overcome social anxiety than avatar therapy did in other studies.

Critics have bigger concerns, as well. Among them are patient confidentiality and safety, which can be problems in an environment like Second Life, where people can adopt any persona via an avatar and easily enter a wide range of sites and situations. In addition, there are no uniform guidelines for teletherapy, so psychologists must learn the current state of the field to avoid a range of legal and ethical pitfalls (see Practicing distance therapy, legally and ethically).

On the business side, psychologists have been hampered by a fear of learning new technology and the lack of a good business model that can provide potential clients with the information they need to sort through quality offerings versus ineffective or harmful ones. Still another concern is the use of avatars themselves: Are there ways that donning alternate persona, even those that may resemble you, change the way you act in therapy?

Psychologists and businesses are figuring out ways to address at least some of these concerns. For one, they're developing secure, HIPAA-compliant platforms in which patient privacy and confidentiality are well-protected. Some entities, such as the Online Therapy Institute (see Virtual training tools), are creating informal guidelines for using these technologies in therapy, addressing issues such as the proper way to obtain informed consent and how to deal with patients' tendency to reveal potentially traumatic information too quickly in such environments, says institute co-founder DeeAnna Nagel.

Meanwhile, some psychologists are talking about ways to make these types of therapy more sustainable in a business sense. Wexler and Roff-Wexler, for instance, discuss these topics through their organization and website Metaverse+ (formerly Psychology 21C), and they welcome other psychologists' input as well (see Virtual training tools).

And while many are slow to adopt such technology, using it is getting easier all the time, and technology quality is improving, others add. "We're getting to the point where you can completely cut through all the prerequisite learning and technical stuff that has been in the way," says Stone. One major breakthrough: A Microsoft gaming program called "Kinect" is now enabling users to create avatars that mirror a person's looks, facial expression and gestures. 

And despite lingering uncertainties, it seems likely that these technologies will keep growing as people figure out business and other applications for them. "The future is going to come," says Wexler, "but which future? Part of our responsibility as psychologists is to understand how these techniques affect human behavior, and to make sure we use them for the good of the client."

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