Abstract
C
One can scarcely go on the Internet today without seeing an article on the latest graphics enhancements, improved pixel quality, the latest head-mounted display (HMD) with superior quality and realism, or the most recent games, applications, and movies—all with heightened levels of realism. It is easy to understand the demand for realism in the entertainment industry. However, when applying this same standard to the therapeutic setting, I wonder if we should consider whether this same realism, which serves well the purpose of videogames and movies, is appropriate, necessary, or even optimal for VR therapy. The question is an important one to ask and to date hasn't been fully explored.
Over the past 22 years, many of us have witnessed the incredible improvements in VR quality but have not necessarily seen matching logarithmic improvements in treatment outcomes or therapy effectiveness. Hundreds of good clinical studies were done with Windows XP systems and admittedly somewhat cartoonish (or what we politely call “low resolution”) graphics, but with the achievement of excellent clinical outcomes. And some of the quite uncomfortable HMDs of the 1990s that have fortunately been retired to a permanent exhibit in the National Library of Medicine allowed patients to experience high levels of immersion and presence.
Lower resolution VR graphics have not seemed to be an impediment, and may oftentimes serve as an advantage during therapy. In a stress management world created in the mid-2000s, a patient from Jamaica traveled through the VR Enchanted Forest and came upon a grove of banana trees and a waterfall. She was immediately transported back to her home and talked about how much she missed her family and needed to plan a visit. Then, entering the same VR world, a patient from China identified the waterfalls as a place she frequently visited in Southern China. These patients both brought their own memories and transformed a computer-generated fantasy world into a place they recognized from their past and felt a connection to based on their own history. By not having a completely photorealistic world, patients from different cultures and with different worldviews were able to receive healing using the same exact VR software and hardware system.
The power of VR is its immersive, interactive relationship between the patient and the VR world that works to bring subconscious memories into conscious awareness. VR is a safe environment that allows the patient to explore and test hypotheses and develop more effective coping skills, strengthening psychological functions that have become weakened or derailed by overwhelming anxiety or trauma. By allowing VR to remain less than real, we give rise to a healing space in which patients can unpack their own special memories, imaginations, and experiences and create their own reality. In so doing, they can change the reality they came to treatment for; they can overcome that fear or trauma or stress-related condition, even learning to change the ending of a nightmare that has haunted them; and they can move forward with renewed self-confidence and self-efficacy.
A patient came for treatment after being in an automobile accident in which she suffered multiple injuries. A passenger in her car had been killed on impact. The accident wasn't her fault, and she knew that logically, but the emotional processing took time. After several sessions of skill building, VR exposure was attempted. In the first session, no VR could be done; she chose instead to grip a steering wheel in the real world while staring at a blank computer screen and allowing the tears to flow freely. But slowly and with physiology monitored to ensure that she did not become overwhelmed or re-traumatized, she was able to enter a less-than-real world and begin healing. Knowing that it wasn't real allowed therapy to begin, and the VR became real to her. When she became immersed in the VR world, she instantly flashed back to that traumatic moment in vivid detail, on a freeway far from San Diego that had been the start of her posttraumatic stress disorder. With time, she overcame her fear of driving, achieving and surpassing her therapeutic goals, able to drive whenever and wherever she chose and using driving as her relaxing “me time.”
As we continue our journey in VR, let us remember to remain more patient centric and therapy oriented and less technology driven. Let us carry on our search for the correct “dose” of VR for each patient, knowing that some patients may need more realism than others, that one-size doesn't fit all, and that we must have some level of flexibility.
We have not yet fully begun to explore all the possible uses of VR in healthcare. At Cyberpsychology, Behavior, and Social Networking, we continue to seek out clinical studies that have shown significant and unique advantages using VR interventions, with a focus not on the technology, but rather on validated clinical outcomes and where applicable significant economic benefit. We must never lose sight of what is truly important: maintaining therapeutic rapport, increasing patient empowerment, and improving quality of care and patient access.