Audrey Hamilton: Virtual reality technology is not just for gamers. Over the last decade, research into advanced virtual reality therapy techniques has shown it to be effective for people with physical and psychological disabilities. A psychologist at the forefront of this research tells us how virtual reality is helping people literally face their fears and learn to overcome them. I’m Audrey Hamilton and this is “Speaking of Psychology.”
Skip Rizzo is the director for medical virtual reality at the Institute for Creative Technologies and a research professor at the University of Southern California. He conducts research on the design, development and evaluation of virtual reality systems, focusing on clinical assessment, treatment rehabilitation and resilience. Welcome, Dr. Rizzo.
Albert Rizzo: Hi, thank you for having me here.
Audrey Hamilton: Your work in developing virtual reality therapies focuses on combining advancements in computer technology with psychological science. How is virtual reality therapy being used in clinical settings right now?
Albert Rizzo: Right now, the biggest use of virtual reality in clinical settings is probably in the area of exposure therapy and that is probably because the technology is well-matched to the needs of the clinical application. We see with exposure therapy the goal really is about helping a patient, whether it’s due to a simple phobia or PTSD, to engage, to confront and to process difficult, traumatic memories.
Now, in the traditional format, you typically do that in imagination alone. But, when you have a disorder where avoidance is one of the cardinal symptoms, sometimes patients may need a little extra boost. So, if we can put them in simulations that mimic or resemble some of their traumatic experiences and do it in a gradual, yet progressive hierarchical fashion, then it really is well-matched to what the need of the clinical approach is.
Audrey Hamilton: Can you give us an example of how exposure therapy works and how the virtual reality therapy works in this type of therapy?
Albert Rizzo: Well, exposure therapy has been around for quite some time. It’s a behavioral approach that’s been applied initially for persons having a fear of heights, fear of flying, fear of spiders. And the therapist typically guides the patient in imagination to gradually get closer and closer to what it is that they fear. And by a process of extinction learning – which is basically face your fear and it becomes less frightening once you actually confront it – what happens is patients lose that, sort of, irrational fear.
Now we’re talking about fears that aren’t real – in real life kinds of fears. We’re not trying to get somebody to jump in through traffic or swim with sharks or anything like that.
Audrey Hamilton: Right.
Albert Rizzo: We’re talking about things like somebody that lives in New York City but has a fear of snakes and they won’t leave their house even though there’s very unlikely chance there are snakes in LA – I mean in New York – aside from Wall Street. Maybe I should have a better example there.
These are fears that debilitate people in functioning in their everyday life. So the fear of flying – you know, it’s pretty safe to fly compared to driving in a car, actually. They are fearful of flying if they do exposure therapy. Typically, you get a good – very good treatment response where they confront that fear in the therapy session and it carries over to the real life.
In VR what we try to do is to help that process along by putting people in simulations of their fear environment and then systematically making it a little bit more provocative once they’ve attained a certain level. So if it’s fear of flying, they’re in a plane and they’re flying along and you can turn your head and look around, see the passenger, look next to them, look out the window. But then once they’ve gotten through that then maybe you want to introduce a little turbulence or a thunderstorm and we can do that with the technology and make it a little bit more scary and the longer we can get the patient to stay with it, all of a sudden that fear kind of fades away and extinguishes, as we call it in psych literature. It carries over from the virtual environment, which is very similar to the real world in a lot of ways – so that people can now start taking flights and not being as frightened.
Audrey Hamilton: Other than exposure therapy, are there any other clinical settings where this is being used?
Albert Rizzo: Pain distraction is a big area where VR makes a big difference because if you put someone in a virtual reality headset, you’re including their view of the wound site and while they’re getting their daily wound care, say for burn victims, they’re engaged in playing a game and they’re in their own world so-to-speak so that what you see from the research is dramatic decreases in the perception of pain and there’s a lot of theory behind why that happens, but it works and people spend a lot less time between pain delivering sessions, like with the daily wound care, thinking about pain, worrying about pain. So, that’s one area where we’ve seen dramatic clinical results.
We also see results in assessment, you know, where we’re putting people in simulated environments and asking them to respond in a cognitive fashion. So for example, with children with attention deficit hyperactivity disorder, we built virtual classrooms where we can put kids in the classroom. They have to pay attention to what goes on the blackboard or what the teacher says. Meanwhile, we’ve got kids sitting next to them fidgeting, throwing paper airplanes, maybe a school bus driving by the window. So we can begin to measure cognitive performance under a range of challenges, but also the challenges of the everyday life environment of the classroom where distraction is a lot different than if you’re testing a child in a quiet office environment in the therapist’s office or the clinician’s office.
Audrey Hamilton: It sounds like virtual reality therapy has come a long way. How has work with military veterans, particularly those who served in Iraq and Afghanistan, encouraged more research into this type of therapy for conditions such as post-traumatic stress disorder?
Albert Rizzo: So what happened around 2003 as the Operation Iraqi Freedom adventure took place, we started seeing more and more people coming back with PTSD. And the military recognizes, as well, and so they began to focus on novel treatments, ways to get people engaged in treatment and virtual reality was one of those areas where they were well familiar in the military with simulation technology for training, but not for clinical care. So, it was new to them, but they stated seeing the results from civilian literature showing that, you know, you can get a good clinical outcome using virtual reality in this area. So, they funded significantly a lot of the basic research that developed these applications and to test them. And so we began building a virtual Iraq and Afghanistan simulation around 2004 and have progressively grown the application based on feedback from clinicians and patients that we’ve treated and have gone through probably four iterations now to very high fidelity environment that has smells…
Audrey Hamilton: Really, smells? Wow, interesting.
Albert Rizzo: Bad smells.
Audrey Hamilton: Yeah, not good ones.
Albert Rizzo: Diesel fuel, rotting garbage, burning rubber, things like that. But we created a multi-sensory environment so that we can help a patient who is typically avoidant to go back and confront and process those difficult emotional memories and get a good therapeutic outcome. So, we’re really basing the use of virtual reality on the evidence-based treatment of trauma-focused therapy prolonged exposure or cognitive processing therapy or EMDR, where people are really encouraged to confront things that emotionally hurt them initially and process them in different ways.
So, that’s an example of where the military has really driven the technology and the application, but now we stand poised to translate that to civilian application. So, the first thing you think of is urban warfare with the police department or firefighters or victims of terrorist attacks. We’ve got the technology to do this and a lot of that has to do with the urgency of war driving a need to develop better treatments for PTSD in military population.
Audrey Hamilton: You have said that virtual reality therapy can help reduce the stigma of mental health treatment. Can you elaborate on that and why do you think that is?
Albert Rizzo: Well, if you look at any virtual reality environment at first blush it looks like Call of Duty or looks like any common game that people play for entertainment. And our view has always been that if you want to draw a digital generation of service members into treatment, why not use some of the things that they’re more comfortable with as a draw?
So, the idea of using virtual reality to deliver exposure therapy was in one part informed by theory – that we knew we were working from an evidence-base with traditional treatment, but the other part was the idea of maybe getting a 20-year-old that played a lot of video games growing up to look at this and say, “Wow, you know, I can maybe get some help and this almost kind of looks like fun.” But in reality, once they try it, it’s not a game anymore.
Audrey Hamilton: Right, right.
Albert Rizzo: Because, we’re really, we’re really pushing them to …
Audrey Hamilton: But it gets them in the door a little easier.
Albert Rizzo: Yes. Yes. And I think you can say the same thing in the future for everybody whether they’re service members or not, millennials, the current generation, the younger generation coming up, you know, this is ubiquitous technology that they see everywhere.
You know, clinicians at their peril may ignore this because they feel it may impair the therapist/client relationship, but actually, in some cases, I think it brings the therapist to a closer understanding of what the client has gone through. When a client is going through a simulation of a traumatic event, for example, the therapist is seeing it. I mean, they’re seeing what the patient sees in the simulation and then that becomes grist for the mill of discussion.
And you know, we are basing it on a traditional face-to-face format where the whole session isn’t conducted in VR. There’s 30 minutes in VR and the rest of the session is processing what went on in the session. When a patient describes a scene and the clinician has a control panel where they can make elements of that description appear in the simulation, all of a sudden they’re looking at it themselves and they’re hearing the sounds of maybe somebody screaming after an IED goes off or a jet flying over. You know, I think in some way, they’re getting closer to the patient compared to just the patient’s narration as they imagine it in their head.
Audrey Hamilton: Well great. Dr. Rizzo, thank you so much for joining us.
Albert Rizzo: OK, thank you. Thanks for having me.
Audrey Hamilton: To see video examples of Dr. Rizzo’s work, please visit our website. With the American Psychological Association’s “Speaking of Psychology,” I’m Audrey Hamilton.