The treatment of psychological ailments like post−traumatic stress disorder (PTSD) has moved beyond the therapist's office and into the digital realm, allowing patients to face their fears from behind a computer screen.
The goal of so−called "cybertherapy" is to make use of virtual environments and virtual humans to facilitate the treatment of some mental disorders. The cybertherapy trend began to emerge as computers gained popularity. As humans became constantly connected, more software programs were developed that could provide therapeutic opportunities, according to Albert Rizzo, the associate director for medical virtual reality at the University of Southern California's Institute for Creative Technologies.
"People realized that virtual reality would be a useful tool to deliver therapeutic modalities," Rizzo told the Daily. "Before virtual reality, therapists relied exclusively on imagination and guided imagery."
Virtual reality was originally a useful tool in a process called exposure therapy, in which a patient with a phobia is continually exposed to the object of their fear until they are no longer afraid of it, a psychological phenomenon called extinction. Using virtual reality, therapists can create environments in which a patient can face their fears right in the office, Rizzo said.
"With virtual reality, whole worlds could be systematically adjusted," he said. "With just a couple of keystrokes, we could move them closer to what they fear."
Since cybertherapy's inception, the capabilities of virtual reality have grown immensely. This, along with the collection of hard data and the widespread use of the Internet, has prompted the growth of the field, according to Rizzo.
"We can do what we did before in a tenth of the time, at a hundredth of the cost," he said.
Rizzo attributed much of the field's current creative ability to the many advances in graphics driven by the gaming industry.
As the field has expanded, its range of applications has as well. Although initially just a useful tool in exposure therapy, cybertherapy now runs the gamut from social skills therapy to the treatment of addictive behavior. It even makes use of specialized interface devices comparable to the Nintendo Wii.
"People can interact in a game−like context, which makes the treatment more motivating," Rizzo said.
Virtual reality can be a helpful tool not only for patients but for the therapists treating them as well. Developing artificial intelligence software can provide training for these therapists, according to Jonathan Gratch, associate director for Virtual Human Research at the University of Southern California.
"There's a focus on training health care providers, using virtual patients to practice doing assessments," Gratch told the Daily.
Gratch's current research project, however, is the SimCoach, a virtual human program designed as a medical navigation tool for war veterans.
"The goal is to help soldiers and their families find appropriate health care treatment," Gratch said.
The SimCoach provides a virtual person for veterans — traditionally averse to seeking out treatment for problems such as PTSD — to open up to about their difficulties. SimCoach can then make suggestions as to possible treatment options.
"Instead of being stigmatized, they can be anonymous," Gratch said.
One other treatment option for these veterans is a cybertherapy program that Rizzo is currently developing — a virtual reality program in which a virtual Iraq or Afghanistan can be rendered for the purposes of exposure therapy. To experience the environment, the patient dons a headset and is seated on a platform that can simulate the vibrations of a vehicle or the explosion of an improvised explosive device.
"The purpose is for the soldiers to revisit and confront the traumatic events they experienced," Rizzo said.
The rendering of a virtual environment such as this also allows for soldiers to be tested before they leave for war. Therapists can take the same environment, put the soldiers in it and attempt to determine if the soldiers are likely to develop PTSD later on. Additionally, soldiers can be trained to avoid developing PTSD, again using the same virtual environment.
"We call it the ‘emotional obstacle course,' and we can train [the soldiers] to habituate before leaving," Rizzo said. "We can train coping strategies."
One inherent difficulty in virtual therapy is the realism of the experience. However, according to Rizzo, how realistic virtual therapy needs to be depends entirely on the application.
"In terms of exposure therapy, [patients] are primed to react to anything that looks like what they're afraid of," he said. As such, graphic detail is unnecessary.
However, in terms of using virtual humans as a therapeutic tool, the degree of reality is much more important. According to Gratch, separate studies have shown that in dealing with a stigmatized illness, anonymity and a personal relationship have both been shown to be beneficial.
"Anonymity is very important because the patient will be more truthful, but interacting with a person can be more engaging," he said. "With virtual humans, the hope is to get the best of both worlds."
There is currently a push to model more realistic behavior in virtual humans.
"At this point, they don't necessarily personalize themselves to you," Gratch said. "We want it to have more intelligence and persistent memory, so it remembers you and builds rapport."
Although the realism of virtual humans continues to advance, cybertherapy's future lies in remote interaction with a therapist, according to Rizzo.
"The ethical question is: Does the therapist have to be in the room with the patient for good therapy to occur?" he said.
Rizzo believes this is possible and that remote interaction provides numerous options to deliver care. David Harder, a professor of abnormal psychology at Tufts, however, sees some potential pitfalls in this form of remote therapy.
"They can't see the client, and the client can't see the therapist, which can reduce the human elements," he said. "The therapist doesn't have the cues that they'd have in a face−to−face interaction."
Harder said that from a legal and ethical standpoint, neither the quality of care nor the qualification of the therapist can be guaranteed. "On the client's end, they don't know who they're talking to," Harder said.
The pros of cybertherapy may outweigh the cons, however, as remote therapy is only a single application of the technology. The possibilities that virtual environments and virtual humans provide are driving the field into the future, Rizzo said.
"We really want to know how we can use these simulations to treat people with clinical disorders in ways that we can't do in the real world," Rizzo said.
