How Virtual Reality Is Being Used to Heal
Virtual reality has a reputation for transporting the user into a science fiction dream. You can fly over ancient cities or swim through caves along the sea floor simply by slipping on a headset that loads one of these unique interactive software environments, delivered in high-definition 3D. But what you may not know is that clinicians and researchers have been developing VR environments that can change the way that we experience things in the real world, too—like post-traumatic stress, phobias, pain, and so much more.
For more than twenty years, Skip Rizzo, a clinical psychologist and the director for medical virtual reality at the University of Southern California’s Institute for Creative Technologies, has designed and researched innovative VR environments. They’re used clinically to improve a patient’s psychological, cognitive, and motor abilities. Rizzo and his team at USC developed Bravemind, a VR environment for veterans with PTSD that transports them back to the moments of combat that haunt them in order to help them face their trauma and heal. It’s called simulated exposure therapy. Working with a clinician, veterans are gradually guided into these VR environments while their physiological responses and stress levels are carefully monitored. Over time, their reaction to the war stimuli is lessened and their symptoms of PTSD in the real world start to become more manageable. Bravemind is currently used at over sixty sites, including VA hospitals and military bases. Rizzo thinks VR has broader potential for other medical uses and that it could play a crucial role in shaping the future of personalized medical care.
A Q&A with Skip Rizzo, MS, PhD
I was trained as a clinical psychologist and as a neuropsychologist, and back in the late ’80s, early ’90s, I was working clinically in brain-injury rehabilitation. I was very frustrated with the types of tools that we had to help people recover their cognitive function and get back into their everyday life after a brain injury. This involved a lot of paper and pencil workbook exercises that most clients found to be really unengaging. One day, one of my clients, a twenty-two-year-old man with a frontal lobe injury, came into my office. He said, “Skip, I got this new thing I’ve got to show you. It’s a Game Boy.” It had just come out. And he goes, “Watch.” I watched him for fifteen minutes—he was glued to this little device, playing Tetris. And that kind of opened my eyes. Here was a kid I couldn’t motivate for more than ten minutes on a traditional brain injury or cognitive rehabilitation activity, but he was glued to this digital toy, and he was getting better at it. That was the first lightbulb that went off: Could we use this kind of game technology to engage people in rehabilitation? Get them to have sufficient focus and do the trials needed to start to recover their attention, memory, and visual spatial abilities?
Shortly after that, I’d heard a little bit about what virtual reality was all about because back then there was a lot of hype surrounding this “first wave” of VR. I went to a conference on virtual reality and people with disabilities but didn’t see anybody doing anything in this area. The next year in 1994, I wrote a paper on why VR would make a big difference in using simulation technology for brain-injury rehab, and it got a little bit of excitement at the conference.
Finally, in 1995, I left my clinical work and took a postdoc at the University of Southern California with the idea that we could build a clinical VR lab. I met some programmers, some computer scientists, and some professors who were really excited, and they shared their equipment with me and gave me some programming time. So in 1996, we built our first VR application.
Back in the ’90s, when I’d have to make the hard sell for this to psychologists, I’d spend half my talks at conferences just describing what the technology was and why it was cool, before I even talked about what we actually did with it. It got better when I figured out that I could just give them a good metaphor. I’d say, “When you’re flying home from this conference, would you rather that your pilot learned how to deal with wind shear or a fog landing from a book, a PowerPoint lecture, or maybe on-the-job training? Or would you prefer they were trained and certified in an aircraft simulator?” And then they kind of got the point.
Twenty years ago, had I known it was going to take this long for this stuff to catch up with the ideas, I might’ve chickened out and done something else. But I stuck with it because I always thought that we’d be there by 2000 or 2005. It’s been a slow crawl, and gradually all the pieces have fallen together. Over time, all the enabling technologies to do good mixed-reality VR, augmented reality, and so forth started to get better. The computer processing, the computer graphics, the interface devices, the body tracking, head-mounted displays—it all sort of came together around 2013, with Oculus being bought by Facebook. Significant investment was put into that area, and then all the other competitors dove into the market.
“Would you rather that your pilot learned how to deal with wind shear or a fog landing from a book, a PowerPoint lecture, or maybe on-the-job training? Or would you prefer they were trained and certified in an aircraft simulator?”
Now I think we can safely say we have success on two fronts. Number one: The technology has in fact caught up with the vision. We can do things with really high-quality VR devices that we only dreamed of just ten years ago, at a cost that makes it possible for wide-scale dissemination. Number two: People like me who saw this vision for using VR and simulation technology in clinical areas early on continued to do the needed research, and consequently, we now probably have the largest, most evolved scientific literature of any virtual reality use case in mental health, rehabilitation, and general medical apps. A lot of research has been done, so now we have good scientific guideposts that help direct us toward: How do we safely use it with patients? Where does this stuff work or matter? How do users respond to it? How do we activate emotions in a therapeutic way that can help people overcome their fears, face new challenges, learn new skills, or be engaged in a rehab activity?
You can distill the key aspects of VR down to five core elements:
You can expose people to provocative environments to help them confront and reprocess difficult emotional memories, as we do with PTSD exposure therapy with the Bravemind system. You can distract users from acutely painful medical procedures. You can motivate patients to do the rehab or a treatment that they might not ordinarily do. You can measure what they do in a very systematic way—it’s the ultimate Skinner box: a controlled, simulated environment where you can measure performance. And just like the Game Boy, this stuff can be really engaging. You’re giving people immediate feedback that’s very precisely tied to their activity in the virtual environment, which can be very helpful for patients. We put games in it.
It’s also a safe place to do things. If you’re teaching somebody who’s had a brain injury how to operate in a kitchen, the traditional method would be to actually bring them into a real kitchen with occupational therapists and have them practice on the devices, but that can be dangerous. They may burn their hand on the stove because they haven’t operated in the kitchen for a while and have lost some of their function. Well, now they can start to reacquire that function in a virtual environment, in a safe way.
When I say VR, I’m really talking about the whole field of mixed reality, where sometimes it’s immersive, sometimes it’s on a flat screen, sometimes it’s seen through see-through augmented reality glasses with a graphic image projected into the real world.
Bravemind started in 2003, as a way to deliver PTSD exposure therapy. And since 1994, basic phobias and anxiety disorders have been addressed using the same process. But there are many other areas where the literature has evolved and people are getting benefits, like pain distraction, where VR is used to help people by distracting their attention away from an acutely painful medical procedure. For example, in burn wound care, when you give patients a headset and put them in an environment where they can either relax or play a game, it draws the attention away from the pain site, relieving the perception of pain dramatically.
For physical and cognitive rehab, we can put people in simulations that represent real-world contexts but give them activities that can be paced to their level of ability at the time and help them continue to do these mental or physical exercises in a gamelike context where they get feedback that shows them they are improving in ways they might not visibly see. If somebody who has physical impairments from a stroke or traumatic brain injury uses a headset, we can help them play and also do rehab. They’re moving their body, and we’ve got good body tracking, so what they do physically can be represented or enhanced in a virtual environment. We’ve all learned from the game industry how compelling and engaging it can be.
“We can create these emotionally evocative experiences, transport people to places, and have them do things that they might never have the opportunity to do.”
Also in the cognitive area, we can do assessments, measuring function in a complex environment. A lot of work has been done with immersive virtual classrooms, where we can have children perform an attention task on a whiteboard at the front of the class or administered by a virtual teacher and then manipulate distractions that might occur in the real world, like kids throwing a paper airplane or a school bus going by the window. Using this approach, we can systematically assess how susceptible a child is to distracting stimuli in a relevant realistic environment.
Another area where there’s a lot of interest and now some emerging research is with elderly folks. The company MyndVR produces a system using standalone headsets that they license to nursing homes and care facilities, where a staff member comes in the room and says, “Okay, what would you like to do today? Go fly-fishing in Idaho or go up to the top of the Himalayas or experience being underwater with dolphins?” There’s an incredible amount of content, and it’s very easy to use. They now have the beginnings of some data to show that when people have those breaks from the doldrums of their everyday living situation, they feel better and are less agitated. We can create these emotionally evocative experiences, transport people to places, and have them do things that they might never have the opportunity to do. Hopefully we do it in a way where they can grow from it or they can simply feel better.
I really think it’s not just about building spaces that people operate in but about populating those spaces with virtual humans that people can interact with. This is another area that we’ve focused on since about 2006. For example, we’ve done training applications for high-functioning people on the autism spectrum on how to survive a job interview and we use virtual humans in it. You’ve got six different characters with different ages, genders, and ethnicities, and we can put them in different job settings, like an office or a warehouse or a restaurant job. We can also change the characters’ levels of provocativeness to make them nice, kind of neutral, or cranky to give people practice in dealing with different interviewers.
We’ve published positive results on that with autism, and now we’re expanding that by building a system focused on helping veterans survive job interviews. They may have certain challenges around trying to represent themselves and their military experience and also fielding inappropriate questions, like “Oh, you’re a veteran. You don’t have PTSD, do you?” How do you prepare for those things?
We also have a project down in Florida with the Dan Marino Foundation, working with incarcerated juveniles who are about to turn eighteen and be released. They’ve got their hands full figuring out how they talk about why they were incarcerated as juveniles or how they’ve been rehabilitated. So we can give people that kind of practice under a range of challenging conditions.
“The World Health Organization says that around 60 percent of people in the US with mental health problems never see the inside of a therapy office.”
Our team is also building intelligent virtual human agents that you can access online and on mobile devices to have a conversation with you about your health care in a safe, private, anonymous way. You can choose to talk to a virtual person who represents a clinical expert and you can get information. We did one for the military where the character would ask questions in a conversation that were thinly veiled screening questions for PTSD, and at some point, the character might say, “Hey, looks like you’re having a bit of trouble here. If you want, you can punch your zip code into this little box here, and I’ll pop up a list of providers in your area, and you could ask me questions about what treatment involves.” This is not meant to replace a live clinician but rather to help inform someone who may not even know they have a problem or who doesn’t want to talk to a real person about it in that moment. You can maybe help them put a toe in the water and fill in gaps where clinical providers are not available or where a person may not feel comfortable discussing their issues. The World Health Organization says that around 60 percent of people in the US with mental health problems never see the inside of a therapy office. Maybe this approach could help people seek mental health support that they wouldn’t otherwise receive from a real clinician.
There’s such stigma around seeking mental health care, and it shouldn’t be that way. I’ve seen people, particularly people with PTSD, who go decades with emotional pain and don’t seek help. So there are a whole bunch of areas where virtual humans and the growing evolution of artificial intelligence that will underlie those virtual humans’ interactions with real people will continue to grow.
I think that all the excitement about virtual reality, for better or worse, is building public awareness, and the challenge, up to the last couple of years, has been the cost and complexity of delivering this stuff. When we built our first Bravemind PTSD system, it required two computers and a complex system that cost about $15,000 for everything. Now we can deliver it basically with about $4,000 worth of equipment, including the computer.
In the future, the costs will come down further. We already have stand-alone VR headsets that do all the computing without an external computer, like what you see with the Oculus Quest. That type of system is very low cost—about $200 to $400—and there are now many clinicians who use such systems and software packages for pain distraction, fear of flying and heights, or even fear of public speaking. Once a clinician can open up their desk drawer, pull out a headset, and hand it to a client, and then maybe from their laptop or tablet, they can control what goes on in the environment, that’s when things will get much more visible and feasible.
With that said, we’re working with the Soldier Strong Veterans Foundation and the VA to distribute Bravemind to every VA in the country because of the low cost and research that has shown that it’s an attractive option for delivering this evidence-based approach to PTSD therapy. So we’ll have some visibility, and maybe that’ll grow the other areas, like the phobia work, which is starting to get some uptick. And awareness, anticipated benefit, and documented research to support VR’s value could continue to build.
I think that if VR headsets (particularly standalone headsets like the Oculus Quest, VIVE Focus, and Samsung Gear VR) ever become so commonplace that every home has one, people will have more experience with VR and will want to have some of their health care and education delivered in these simulated environments.
I do have some concerns about self-treatment without clinician supervision. Typically, the early adopters of VR for anxiety disorders and PTSD are clinicians who have had systematic training in exposure therapy and know what they’re doing as far as the therapeutic process, so now they’re implementing VR to supplement the patient’s imagination. With PTSD, before we will send a system out, we require that a clinician documents that they’re certified in prolonged exposure therapy and that they’re going to commit to going to a VR training where they get familiar with the equipment and the concept. It’s about learning how to operate a new tool to do what they already know how to do. There should be a certification program and continuing education though. As the field evolves, you’ll start to see some of that, because I don’t think clinicians should just be able to go out and buy a VR therapy tool in order to advertise that they are state of the art. If they don’t know how to operate that or how to deliver that therapy to begin with, that would be unethical. This already is the standard with psychometric tests: You have to show that you’re a licensed clinician to get access to these things.
So there’s always a place for informed ethical caution. If you want to brag about how powerful the technology is for good, you’ve got to also accept the fact that it’s a powerful, emotionally evocative technology that can be used in a negative way. The axiom in medicine is to first do no harm. Safety and caring about the integrity of our patients are the hallmark.
We’re not saying replace clinicians with software. We’re not saying spend all your time in VR. In fact, most treatment uses of VR last around twenty minutes. It’s not like you’re in it for hours. I’ve had well-known clinical experts come to me and say, “Whenever you use technology in any kind of therapeutic context, you’re putting a barrier between yourself and your client.” But take a look at the PTSD work: You have the clinician right there with a patient constructing their trauma experience in VR in real time. Patients pick the virtual world that they want to be in that’s most relevant to their trauma. The clinician can adjust the time of day or make a bomb go off somewhere or have an insurgent pop up. And clients have actually said, “I feel like my therapist understood what I went through better because they’re creating it and they’re seeing it.” That is not putting a barrier between yourself and the client; that’s having a shared experience.
Albert “Skip” Rizzo, MS, PhD, is a clinical psychologist and the director of medical virtual reality at the University of Southern California’s Institute for Creative Technologies. He holds a master’s in experimental psychology and doctorate in clinical psychology. He is a research professor in the USC department of psychiatry and behavioral sciences as well as at the USC School of Gerontology. For over twenty years, he has researched virtual reality systems for clinical applications.
This article is for informational purposes only, even if and regardless of whether it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of goop.