Virtual Treatments, Real Results: Virtual Exposure Therapy in Psychiatry

Barbara O. Rothbaum, PhD

Dr. Rothbaum is Professor in Psychiatry, Director, Trauma and Anxiety Recovery Program, Emory University School of Medicine

Background

Dr. Barbara Rothbaum and colleagues first examined psychiatric applications for virtual reality in a controlled study on treating fear of heights. Published in 1995, the study was, in Dr. Rothbaum’s words, “a test balloon to see if we were on the cutting edge or the lunatic fringe.” The answer soon came as 70% of the study’s patients transferred their virtual reality therapy and were subsequently able to expose themselves to real-world heights. The experiment was a success and the use of virtual reality in therapy was firmly established on the cutting edge. And, with increased efficacy and constantly expanding applications, that’s where it’s likely to stay.

Virtual reality therapy has been used predominately in psychiatry for treating anxiety. Originally, the technology severely limited its applications; graphics and animations were relatively primitive, and hardware was very expensive. Fear of heights was an ideal test case, as it involved relatively simple computer graphics (lots of straight lines) and little-to-no patient movement, and height cues could be rendered well in virtual reality. Early use was also limited due to the complexity of the software and hardware.

“When we started, I needed a computer scientist by my side the whole time to make everything work on the $150,000 computer work station,” Dr. Rothbaum says. “Now, it all runs off of a desktop or laptop, and it’s designed to be used by computer-illiterate therapists.” The company Dr. Rothbaum founded, Virtually Better, Inc., produces and distributes software and virtual environment packages.

Current Uses

Advances in technology—particularly better computer animation, enhanced patient mobility and interactivity, and even importing images taken with 360-degree cameras—have since enabled wider-spread applications. The most well studied and widely used of these to date is virtual reality treatment for fear of flying. “Using virtual reality to treat fear of flying has worked very well,” Dr. Rothbaum says. It has a number of advantages over traditional exposure therapy, which required multiple sessions with actual airplanes—not only costly, but a huge hassle, and, Dr. Rothbaum suggests, a near-impossibility to arrange in the post-9/11 world. Another advantage is that patients know they’re in no actual danger with the virtual reality airplane and may be more willing to undergo therapy. While the skeptic might suspect that this lack of fear would undermine the treatment’s efficacy, studies have shown otherwise.

According to Dr. Rothbaum, “most patients end up feeling the same sort of anxiety they would feel in an actual plane. After transfer, when they’re in the real plane, they report that the techniques they used to deal with their anxiety in the virtual plane are similarly successful in the real one.”

The great advantage of virtual treatments is their ability to expose a patient to environments and situations that, in the real world, would be difficult or impossible to arrange. This is perhaps best represented by virtual environments for the treatment of PTSD. Currently, there is a virtual Vietnam and a virtual World Trade Center being used in studies, and studies are about to begin with a virtual Iraq. These sorts of environments, in which a patient has almost total free movement, may have tremendous therapeutic use, but clinicians should carefully screen patients, as Dr. Rothbaum warns, “the reactions to these virtual environments can be very intense.”

Virtual audiences are also being studied for treating fear of public speaking, which is the most common anxiety in America, and one which, due to the need to find and pay volunteer listeners, used to be costly and difficult to treat with exposure therapy. Now, with the ability to edit actual video feed of actors directly into a virtual world, a realistic audience is always readily available and, at the therapist’s key press, can ask questions, laugh, answer cell phones, or applaud.

Dr. Rothbaum and colleagues have recently begun studying possible uses of virtual therapy for treating substance-abuse disorders. They’ve designed a virtual crack-house and a virtual party, and, as Dr. Rothbaum explains, “exposing a patient, in a controlled environment, to the cues that trigger their desires to smoke, drink, or use drugs, offers them the opportunity to learn coping mechanisms that they can then go on to use in real life and to see that repeated exposure to these cues without using can weaken their strength to induce craving.”

Future Uses

Dr. Rothbaum believes that virtual reality has a great deal of untapped value, not just in treatment, but in research and training as well. “One possible application is in conjunction with brain-imaging,” she says. “This is particularly exciting in regard to addiction. If you’re trying to find a drug that inhibits urges, it would be very helpful to have a good idea of what parts of the brain are active when those urges are being experienced. You can hardly take an fMRI to a party, but you can create a virtual party in the lab. This could allow for unprecedented control of stimuli, and could conceivably have wider applications than just researching addiction.”

She also believes that there is a great deal of potential for training. “NASA and the DOD already use virtual reality for training. I believe it could be used in a more psychological way; for example, teaching high-risk kids drug refusal or condom negotiation skills. The kids love virtual reality, so we can engage them and teach them.”

Conclusion

Virtual reality therapy has been adopted in a number of places around the country and the world, but the usage is hardly universal yet. However, with a wide array of treatment applications already being studied, an even larger number of possible future applications, the combination of virtual reality with pharmacotherapy for research and treatment, and decreasing hardware prices making it more affordable, virtual reality applications look to be a part of psychiatry’s real future.

Images courtesy of Virtually Better, Inc. For more information on virtual reality therapy, go to www.virtuallybetter.com.

Disclosure: Dr. Rothbaum owns stock in Virtually Better, Inc.