American Psychological Association
117th Annual Convention
Toronto, August 6-9 2009
L-R: Lt. Col Timothy Lacy MD, Dr. Stephane Bouchard, Dr. Richard Wexler (chair), Les Paschall
Next stop: Virtual Psychology and Therapy
Here was a very dense-packed presentation with some leaders in the use of Virtual Reality (VR) applications, across a wide range of populations ranging from the military to clinical practice situations.
Introductions were made by the panel chair, Dr. Richard Wexler, who began by addressing the topic of virtual environments through the lens of a socio-cultural context. "One quarter of the world population is now on the web", he began, adding that this brings about a whole new set of opportunities: "The time for virtual psychology is today." Today is an era when an entire generation is becoming known as the "V" generation, reflecting their comfort level within virtual environments in which they navigate every day. [Dr. Wexler noted that the company he is involved with, "Virtually Better" has a number of applications which are applicable to more routine clinical use in addition to their efforts at developing a "virtual Iraq" to help with training and treatment relating to soldiers in Iraq. After the presentation I visited the booth, and saw both customizable applications which need nothing more than a PC and a range of more sophisticated and hardware-needy deployments of VR-based applications. Indeed, they are sophisticated.]
The first speaker to present was Dr. Stephane Bouchard, who sought to describe how VR can be a therapeutic tool, "the key" being that it be realistic enough so that "you forget you're in the psychologist's office". A number of "standardized, therapeutic experiences" are utilized via use of VR, and are said to be effective in a range of treatment goals. With anxiety, for example, "the great thing with VR is that you can control the *rate* of treatment". The type of presenting problems includes things like fear of public speaking, or phobias.
Dr. Bouchard cited the work of Rothbaum et al (2000, 2002), oriented towards treating fear of flying, which at the time of the second paper was seeing an increase, post 9/11. They enjoyed a success rate of over 80% using their VR-based treatment approach. They also found, in follow-up, a very low incidence of relapse.
From a business/practice point of view, people do ask, "why invest in VR?". For, say, a spider phobia, why not just grab one from the lawn? ("Because you need to feed the darn thing!")
With phobias at least, there continues to be evidence of growing use and success with treatment, cross-culturally. In a study in Spain, for example, Botella et al (2007) reported positive results in treating panic disorder with agoraphobia.
There have also been successful results in utilizing VR for treatment of PTSD. "Mostly used for in virtuo exposure", VR-based therapy has been used in Vietnam, Angola, Afghanistan and Iraq. It has been used, in addition to being a therapeutic tool, in prevention and supervision activities, as well as in military training, to facilitate acclimation and provide realistic practice. Other uses were illustrated, several involving trauma, as in the case of "Justina", a virtual girl who was raped, and whose persona one can "talk with" in a safe and supportive setting. "What about the realism?" "Does it feel real?" Citing the research of Zimmons (2004), an experiment was described where the subject was asked to throw (virtual) balls into a (virtual) pit, and heartbeat was monitored as a dependent measure, and affirmed that people reacted as they might in a real (non simulated) situation. One thing research has found is that in experiencing VR situations, "we think like an amygdala" (oriented towards basic survival "instinct") so that the converging lines tell us about our height and the depth below and signal if we are in danger, on a very basic level. Cote & Bouchard (2009) worked successfully with eating disorder treatments using VR, while Hoffman et al had good results working with VR as a means of minimizing awareness of pain. Other work has focused on identifying sexual preferences, with the equipment tracking one's visual focus when presented, for example, with nude images of males and females - in the case of sexual offenders one can see the response to different presentations of children and adults of varying age and gender. There has also been research into VR as a treatment tool with schizophrenia (Fornells & Ambrojo, 2008), in providing social skills training (e.g., a recent Korean study), and in reducing cravings among addicts (Bordnick et al) . In conclusion: VR has a well-established and documented efficacy as an agent of therapeutic change. If there were a summary "take-home" message to impart, it would be: 1) Yes, it's effective; and 2) We need to remember that it's only a tool that supports a good psychologist's skills.
The next presenter is Lt. Col Timothy Lacy, MD (a psychiatrist), from the US Air Force Medical Support Agency. His focus has been on military applications, with a goal-oriented interest in "moving from science to fielding solutions". Within a context of long tours of duty, many casualties, and harsh day-to-day conditions, as well as increasing reports of suicide and PTSD among the military, there has been a concerted effort since the release of a June 2007 Dept. of Defense report suggesting that more needed to be done in addressing the rising tide of PTSD. In terms of what was seen in "evidence-based" trials, "prolonged exposure therapy gets the best data" (Difede, Rothbaum, Rizzo et al). The type of virtual environment used to simulate the triggering environment included things like a recreation of driving through Fallujah (Iraq). Critical to keep in mind, "it's not a game". Aside from realism and relevance in general, there has been development of "discreet modules" to address specific contexts and experiences. Thus far there has been great progress. "The question", however, remains: "How much data is enough to move towards deployment?" Within the military the decision was made to go ahead and deploy the system with the best data. Key locations were identified within the Air Force, and it was decided to offer this treatment *as an option* available to personnel. Of those who participated at the Madigan/San Diego base, over 60% showed improvement and "prolonged success". The Madigan Army Medical Center soon identified the key components as training, supervision, and research, combined with a simple system using "Caring Technology". This system involves use of a HIPAA compliant server to begin with, while the military sought to also tighten security along other dimensions.
What is in store for the near future? Lacy hopes to see continued use of "virtual worlds", but not only targeting the soldier but also oriented towards family support and other needs such as anger management training.
Next up: Dr. Walter Greenleaf, of Virtually Better, which offers easy-to-implement VR applications such as described above, and on display at the APA exhibit hall. Dr. Greenleaf spoke about how efforts to create a virtual environment for behavioral medicine led to 25 years of research and development, with the product out there now being the "culmination of a journey" which has been ongoing for decades. He retraced some of the history, from the time his friend and colleague Jaron Lanier coined the phrase, Virtual Reality. He mentioned Rhinehardt, a leader in the field whose background was as a programmer. Until this time of sudden interest and growth, there had been "simulators" (such as for driving, flying, and fighting) but the equipment was unwieldy, at one point requiring essentially wearing "2 bricks" on one's head. Over time the value of VR has been demonstrated in numerous applications, including treatment of stroke and TBI, and in surgical planning. Wiederhold and others helped present platforms and demonstrations to continually improve the technology. Now we can look at avatars which move fluidly, and can be made "culture-specific". There has also been accelerated growth and development due to interest in multi-user virtual environments, driven by the game industry.
So, why use virtual environments?
For children and teens, a big attraction is that "you can change who you are" and experiment with role-playing.
- They are engaging.
- They facilitate active participation.
In conclusion, there are numerous ways VR therapies can be beneficial. In addition to what was already mentioned, VR therapies offer a means to destigmatize therapy. You can review a session any time. You can see the interactions from another's point of view. Finally, you can do "invisible observation and discrete coaching", for example providing feedback through an earpiece.
Last to speak now is Les Paschall, the CEO of CFG Health Systems (cfgpc.com). Speaking from his business/entrepreneurial perspective, Paschall offered the following observation: "Excitement and enthusiasm without a clear financial plan is just excitement and enthusiasm." He clearly focused on the business, and has managed to grow it over the past 14 years. His company uses a variety of methods including VR, and video/teleconferencing. Their role is technological, and the clients are from many types of settings, and utilized by several behavioral professions.
In developing a practice which employs VR applications, one needs to be cognizant of the challenges as well as the benefits:
- Regulatory - E.g., licensing/regulatory constraints in working across borders
- Cultural (Sometimes one may get some 'pushback')
- HIPAA - "On the Internet, can anyone else see your session?"
- Financial - Who's going to pay? Like many business professionals, he looks at Return on Investment (ROI)
- Wide applicability - It can be deployed in China, for example, covering vast distances and without the hassles of, say, the US, with all the states having their own licensing schemes.
Benefits include successes in treatment across a wide range of presenting issues. Recently children with ADD have been added to that list of who might be assisted through VR. Children in general enjoy this activity and many look forward to treatment sessions. There are also benefits to using VR applications in education, as well. "Now is the time", Paschall asserted, although there is still work to do. He concluded his presentation with a photo/slide of the Great Wall of China, where he has just returned from. He recalled what his hosts told him, which he continues to find inspirational: "If this can be done, other challenges seem small".
Disclaimer: I try to ensure accurate reports of study results, names, dates, etc., and use a combination of verbatim notes, presenter materials, Power Point data summaries, and direct follow-ups with presenters. If I have inadvertently misstated or mis-typed any information I would be grateful for any corrections and will promptly update/correct any errors.