Therapy in Virtual Environments—Clinical and Ethical Issues

Abstract

Background: As virtual reality and computer-assisted therapy strategies are increasingly implemented for the treatment of psychological disorders, ethical standards and guidelines must be considered. This study determined a set of ethical and legal guidelines for treatment of post-traumatic stress disorder (PTSD)/traumatic brain injury (TBI) in a virtual environment incorporating the rights of an individual who is represented by an avatar. Materials and Methods: A comprehensive literature review was undertaken. An example of a case study of therapy in Second Life (a popular online virtual world developed by Linden Labs) was described. Results: Ethical and legal considerations regarding psychiatric treatment of PTSD/TBI in a virtual environment were examined. The following issues were described and discussed: authentication of providers and patients, informed consent, patient confidentiality, patient well-being, clinician competence (licensing and credentialing), training of providers, insurance for providers, the therapeutic environment, and emergencies. Ethical and legal guidelines relevant to these issues in a virtual environment were proposed. Conclusions: Ethical and legal issues in virtual environments are similar to those that occur in the in-person world. Individuals represented by an avatar have the rights equivalent to the individual and should be treated as such.

Introduction

Virtual reality (VR) techniques are rapidly becoming more widely accepted and used for the diagnosis and treatment of psychiatric disorders.^1
–3 VR platforms in mental health treatment range from fully immersive (involving the use of head-mounted or large-scale three-dimensional displays paired with sensory stimuli such as audio and olfactory stimuli, designed to give patients the sensation of being completely inserted into a virtual environment [VE]) to desktop VR applications (three-dimensional VEs on a desktop computer where participants interact in the form of avatars that are controlled by the participant through the mouse and keyboard). VR has been used in the treatment of a myriad of psychological issues, including eating disorders,^4

–8 anxiety disorders,^9

–12 and some autism spectrum disorders.¹³ Other uses of VR in mental health treatment include stress management¹⁴ and pain management,^15,16 treatment for cognitive impairment and psychiatric disability,^17,18 and treatment and diagnosis of neurological conditions such as stroke and brain injury^19

–23 and central nervous system dysfunction.²⁴

One of the most effective and widely used VR applications in mental health is VR exposure therapy (VRET), used in the treatment of phobia^25,26 and trauma-related disorders.^27,28 VRET involves the use of VR applications, in conjunction with therapy, to expose patients to visual and other sensory material that represent a feared object or situation or a traumatic event.⁸ VRET allows for attenuation of the anxiety that reinforces phobia or trauma-related symptoms by providing exposure to the feared stimuli in a safe environment.⁸ Moreover, VRET allows for prolonged exposure to the feared stimuli, a vital component of effective exposure therapy, which can be more difficult to achieve in in-person treatment environments.²⁸ VRET has been used extensively to treat phobias, including social phobias,^29,30 fear of heights and flying,⁹ claustrophobia,³¹ and fear of spiders,³² and has also been used to treat post-traumatic stress disorder (PTSD).^{8,28,33
–35} Military organizations now use VRET to treat soldiers and veterans suffering from PTSD^34
–36 and other combat-related disorders, including traumatic brain injury (TBI).^37,38 Immersive applications such as the Virtual Iraq/Afghanistan VRET System²⁸ have been evaluated, and results of these studies lend support to the effectiveness of VRET for PTSD treatment.^28,39

However, further research is needed to examine the effectiveness of other VR applications, such as desktop VEs, for VRET. Although immersive technologies have been more widely evaluated, desktop applications may be more accessible to the average clinician, which may give them greater potential to become integrated into mainstream mental health practice in the near future. Yet, important differences exist between immersive and desktop systems, and unique treatment standards may apply to each approach.

Furthermore, the safety of these approaches must be considered. Further research is needed to assess the safety of VR approaches and identify any risk factors for patient populations that may be incompatible with this modality of treatment. There is evidence that general safety issues exist with exposure to some VR applications.⁴⁰ However, empirical research is limited in this area. The primary safety risks that have been noted include mild to moderate physical and psychological side effects following exposure to immersive VEs. The risks of using VEs in mental health treatment have not been rigorously explored. Physical side effects have been primarily observed with exposure to immersive environments (i.e., head-mounted display-based systems or physically enclosing, large-screen display environments) and range from mild disorientation to VR-induced sickness including nausea, visual disturbances, and disorientation.⁴¹ Psychological side effects that may apply to immersive environments and VEs have been suggested, yet much of this evidence is anecdotal and has yet to be empirically supported.^40,42 Possible psychological side effects of VR exposure include frustration, isolation, addiction, stress, mood change, and hallucinations.⁴⁰ Treatment via VR may be less clinically appropriate for some patient populations than others. Gorini et al.⁴² have suggested that individuals with social anxieties may have increased risk for deterioration or “Web addiction” with treatment in a VE as this may lead to a virtual substitution for real-world relationships. Very limited empirical evaluation exists regarding the safety of desktop VEs for mental health treatment, and privacy and ethical concerns with this treatment platform have been noted.^13,42

It is vital that large-scale studies evaluating critical factors (i.e., patient safety, efficacy, and appropriateness or VR for specific patient groups) are undertaken before the use of VR and VEs in the treatment of mental health issues can be fully established and integrated. However, preliminary ethical and clinical guidelines for guiding this much-needed research must first be addressed. Preliminary guidelines should be established and will naturally evolve as studies are conducted and more data are gathered on this treatment modality. In the present article we focus on the use of desktop VEs in mental health treatment. Although a full evaluation of the safety and effectiveness of mental health treatment in VE platforms is outside the scope of this communication, we discuss ethical and legal considerations for the use of VEs in providing mental health treatment, present a case study of “virtual therapy” to illustrate the potential of this approach, and establish preliminary practice guideline recommendations for the evaluation of mental health treatment in VEs.

What Are the Boundaries for VEs?

Ethical issues surrounding the use of VEs in the provision of mental health treatment have been discussed.^42
–44 However, preliminary ethical guidelines for mental health treatment in VEs, where the patient and therapist are represented by avatars, have yet to be fully established. Practice guidelines have been established for the provision of mental health treatment through other electronic platforms such as online therapy and telemedicine.^45,46 Guidelines regarding informed consent, patient confidentiality, patient well-being, clinician competence, therapeutic environment and process, and emergencies have been established in these fields.^{22,44,47
–49} Similar ethical concerns (i.e., privacy, competency, standard of care, etc.) for clinical applications of VEs have been discussed⁴² but have yet to be fully developed. Extending mental health treatment within VEs could open the doors to treatment and new forms of treatment, such as exposure therapy, for many individuals. However, important differences may exist between established electronic treatment platforms, and the unique ethical concerns arise with treatment in VEs must be addressed. We evaluate these concerns with a central focus on two issues: the establishment of avatar rights and defining practice boundaries for virtual worlds.

Establishment of Avatar Rights

Graber and Graber⁵⁰ have illuminated the issue of avatars' rights. They argue that “as another manifestation of the individual, an individual's avatar should have rights analogous to those of a biological body.”⁵⁰ They assert that intention to be part of or an extension of an individual (evident in the case of transplanted organs or prostheses, for example) is what imbues rights. They argue that “the individual thinks, moves a muscle, and the prosthesis moves. This is the same path taken by an avatar. The individual thinks, moves muscles (in this case controlling a keyboard or a mouse), and the avatar carries out an action."⁵⁰ Moreover, “consciousness need not be biologically present for the representation to have rights as a person."⁵⁰ They note that a person represented by an avatar in a VE can have interactions with others where arguments may occur, and it is the person controlling the avatar who feels insulted. Thus, the avatar should be imbued with the same rights and responsibilities as a person in the real world.⁵⁰ In the context of mental health treatment, the virtual representations of the provider and patient in a VE simply become extensions of the actual individuals, and interactions taking place in a VE have the potential to have equal impact as interactions in a “real-world” setting. Taking this argument to a logical conclusion, it is clear that mental health treatment in VEs must abide by the same clinical standards, ethical guidelines, and laws that govern “real-world” practice.

Establishment of Practice Boundaries for Virtual Worlds

The need for the establishment of rights for individuals receiving treatment in a VE and the establishment of “physical” boundaries for the VE is necessary so that legal and ethical standards can be applied. Legal and ethical rights and needs of the individual represented by an avatar compared with a person in a real-world setting are of great importance. The issues of authentication, confidentiality, consent, and a variety of clinical issues must be addressed for virtual therapy to take place. Questions arise such as the whereabouts of the “physical” location of the VE that the therapy occurs in—is it in the patient's state, the provider's state, or elsewhere? This issue is of great importance in determining provider licensing and malpractice protection.

Theoretically, therapy in virtual worlds could be treated in the same way as therapy via telemedicine to establish boundaries for virtual therapy. In the realm of telemedicine, the current standard of practice is clear on this issue. A telemedicine consultation is considered to take place in the state where the patient is situated, and the provider must be registered and licensed to practice in the state where the patient is.⁵¹ The only major exception to this rule applies in certain federal health systems, such as in the military, Veterans Affairs, and the Indian Health Systems, where providers are considered to be licensed nationally and can work in any facility throughout the systems in which they are employed. This is essential for the good running of those systems where providers have to be frequently redeployed as a matter of urgency.

Thus, two approaches can be taken for establishing treatment boundaries for VEs. In some cases, both approaches may have to occur simultaneously given that both providers and patients from all around the United States may be meeting in the same VE:

1. When federal employees are being treated by federally employed providers, the therapy island itself should be considered to be a virtual extension of a federal facility. All policies and procedures, from legal and ethical standpoints that apply to the host institution (e.g., United States Military Hospital, etc.), would then apply on the virtual clinic. This would protect the rights of patients and providers and bring ethical and legal certainty to the project.

2. When either patients or providers are not federal employees, then the therapy island should be considered as the patient end of a telemedicine consultation and to be located in the state from which the patient is logged in. In effect, the provider must be licensed in that state to consult with that patient, as is the requirement in any telemedicine consultation.

The ethical and legal issues of importance will next be examined, and appropriate clinical solutions will then be recommended to allow virtual worlds to be used for psychotherapy.

Ethical and Legal Considerations for Mental Health Treatment in Virtual Worlds

Ethical and Legal Issues Relating to Telemedicine Apply Well to Virtual Worlds

Although some important differences exist between these treatment modalities (most notably that body language and facial expression information available to the provider with telemedicine formats is lost in the VE modality), it is arguable that because both telemedicine and virtual formats involve providers and patients meeting electronically for therapy, preliminary explorations of virtual therapy should follow the same rules and regulations that govern telemedicine and other online therapy platforms. However, we acknowledge that further research is needed to evaluate differences in treatment standards between VE and telemedicine treatment modalities. In the following sections, we will briefly discuss the ethical and legal standards in telemedicine and how they can be applied to virtual therapy as well as unique considerations for clinical practice in virtual worlds.

Standards in Telemedicine

The Medical Board of California provides a clear summary of the law as it relates to all aspects of telemedicine in California. California is used as the example in this article, but every state has somewhat different state laws that apply to telemedicine, and practice issues consequently vary around the country. The Medical Board of California Website states that: “Telemedicine is seen as a tool in medical practice, not a separate form of medicine [and] the standard of care is the same whether the patient is seen in-person, through telemedicine or other methods of electronically enabled health care."⁵²

The “Telemedicine Development Act of 1996”⁵³ requires that telemedicine practice must follow existing law, that practitioners must be licensed in the patient's state, and that verbal and written consent from patients must be given prior to delivery of care. Moreover, prescribing medications over the Internet is prohibited without a prior examination (in-person or online with sufficient technology to replace an in-person examination).⁵² The Medical Board of California states that “the law governs the practice of medicine, and no matter how communication is performed, the standards are no more or less. Physicians practicing via telemedicine are held to the same standard of care, and retain the same responsibilities of providing informed consent (Business & Professions Code Section 2290.5), ensuring the privacy of medical information, and any other duties associated with practicing medicine."⁵² The telemedicine practice, standards, requirements, and prohibitions from the Medical Board of California are consistent with general practice guidelines and can be extended to a virtual therapy environment, with the acknowledgement that further studies are needed to evaluate differences between these two treatment modalities. For the purposes of preliminary research, the key requirements can be directly applied: for all physicians to be licensed in the state in which the patient resides, for there to be written informed consent and privacy of medical information, and, no matter what the technology, for the standard of care provided to be no different from any other form of care.

Security, Privacy, and Confidentiality

As in any other clinical setting, patient confidentiality must be protected. Information must only be released with patient permission, and the patient must be informed of any exceptions to confidentiality.^48,54 The issue of compliance with the Health Insurance Portability and Accountability Act (HIPAA) in VEs is of great importance. HIPAA requires that any healthcare provider transmitting protected health information electronically must maintain safeguards (e.g., data encryption and file storage security) to prevent disclosure or protected health information.⁵⁵ Some online VEs offer HIPAA-compliant security for confidential communication. For virtual worlds accessed through platforms that do not meet HIPAA standards for privacy and security, additional measures would need to be taken to maximize the security of protected health information.⁴³ Wilson⁴³ has suggested that if using applications not operating on a HIPAA-compliant platform such as Second Life (a popular online virtual world developed by Linden Labs⁵⁶), interactions can be conducted on a “private island” or “Skybox” where access is restricted and security devices can be installed to prevent anyone but the patient and therapist from gaining access. Furthermore, all communication between the patient and the therapist could be conducted through separate, outside encrypted channels to ensure privacy and confidentiality.⁴³ Additionally, we would suggest that any patient information and data should be securely collected offsite and stored outside of the VE on the practitioner's secure HIPAA-compliant server. These measures essentially bring the VE encounter into HIPAA compliance; however, methods to verify compliance must be explored and established.

Consideration of these important legal and ethical issues is essential before providing any form of mental health services in VEs. The type of service provided and the sensitivity of shared information must be evaluated. VEs can be used for a range of mental health interactions including simulations where patients can navigate educational materials anonymously to the provision of treatment where patients and provider are fully identified. The following case studies illustrate the range of services possible in VEs and the ethical and legal considerations that apply.

Mental Health Treatment in VEs: A Case Study for PTSD

The National Center for Telehealth and Technology (T2) is currently exploring the use of VEs to deliver both mental illness education and therapeutic interventions, particularly talk therapies, for post-combat psychological health problems.

PTSD Education

An example of a virtual-world application for mental health education is the T2 Virtual PTSD Experience, developed on the Second Life platform (Fig. 1). The T2 Virtual PTSD Experience is an interactive, immersive educational experience to teach visitors about the causes, symptoms, and help available for post-combat PTSD. The T2 Virtual PTSD Experience is for educational purposes only, and no form of therapy is available within the environment. No identifiable information is collected about visitors, such as avatar name, responses to self-report screening instruments, or any interactions with other visitors. The environment is not staffed by providers and not monitored. Thus, the environment is essentially equivalent to visiting a health information Website anywhere else online.

Fig. 1.

Visitors learn about the causes of post-traumatic stress disorder in the Causes Exhibit market street simulation.

Virtual Therapy for PTSD

The Department of Defense has begun to investigate the use of VR for treatment of PTSD and other combat-related disorders and has developed the T2 Virtual Clinic on a private, access-controlled island (Fig. 2) in Second Life.⁵⁶ Providers and patients are fully identified by their “real-world” identities and must be authenticated at each visit to the island. Anonymity in this environment would be inappropriate for reasons of risk management, patient safety, and consumer protection. In this environment, patients access psychological services through their computers. Patients check in for a scheduled appointment with an automated avatar receptionist, which notifies the provider that the patient is ready for his or her session. They may be directed to complete pre-session assessments using private, secured Web-based assessment tools. Treatment typically consists of a patient and provider directing their avatars to sit in a simulated therapy office and complete a therapy session.

Fig. 2.

Traditional talk therapy, using voice-over Internet protocol technology, may be a good fit with virtual worlds environments.

HIPAA compliance concerns are addressed by using a built-in voice over Internet protocol that is not routed through the VE but is peer-to-peer. Limits to confidentiality are clearly explained to the patient prior to the first virtual session, and the patient must give informed consent prior to any virtual sessions. Moreover, no patient information, progress notes, or therapy scheduling information is stored within the VE or on Second Life servers.⁵⁶ Instead, all protected health information would be accessed and stored separately in HIPAA-compliant, secure electronic records systems. As a result of our experiences developing VE treatment platforms for PTSD treatment and other findings, we recommend the preliminary guidelines presented in Table 1 to guide future research and practice in this area.

Table 1.

Summary of Clinical Guideline Recommendations for Mental Health Treatment in Virtual Environments

1. Patients who are only receiving generic information on an open education virtual reality environment can be anonymous and should not be tracked in any way. Any providers on that island should be fully identified and should have named or numbered avatars that clearly identify who they are and that link to biographies published on a defined public Website so that any patients or users of the island may obtain accurate information about the providers' expertise and interests as would be expected on any health information Website.

2. Patients who wish to move to a secure virtual reality environment for some form of virtual therapy, whether this is individual counseling or cognitive behavioral therapy, should be treated in accordance with the following protocols to ensure high practice standards and legal and ethical processes:

a. All patients should undergo a face-to-face or telemedicine assessment to evaluate patient safety and appropriateness for treatment with this modality, to establish care, to confirm their diagnosis, to create a treatment plan, and to discuss consent. This is particularly important in a potential emergency situation where therapists have to know the physical location of a patient, as per telemedicine guidelines, in order to call for help.

b. All patients should then sign a written consent form if required in the state in which they reside (which can be done electronically), be trained in how to use the virtual environment, be given a tour of the private island, and receive a copy of their diagnostic assessment and treatment plan.

c. Health Insurance Portability and Accountability Act compliance of the virtual environment must be documented, verifiable, and ensured prior to patient contact.

d. If patients and providers are federal employees, then patients can be treated in the virtual environment from any state, by any provider. If the patient or the provider is not a federal employee, the treating provider must be licensed to practice in the state from which that the patient logs in.

e. All providers will have fully authenticated avatars using their real names and will have biographies published that link their professional identities to their avatars for patients to read.

f. Patients and providers will then schedule sessions on the private island for either counseling, cognitive behavioral therapy, or a combination of both.

g. Any major changes to the treatment plan, such as altered medications, should require a face-to-face or telemedicine consultation.

h. Either the provider or patient may at any time either cease therapy or request a telemedicine or face-to-face consultation to review progress.

Conclusions

VR applications and are now increasingly used in mental health, and VEs have great potential for use in the provision of mental health services. We have argued that the rights of avatars are analogous to those of the individual controlling it, so that then logically we must treat the avatar as an extension of the self.⁵⁰ Thus, treatment standards and ethical guidelines for patients seeking treatment in a VE should mirror those of typical clinical practice in the in-person world. In any clinical setting, clinicians must follow the laws of their field and other existing guidelines. General themes in the literature regarding ethics in the use of VR/VE or computer-assisted therapy closely mimic approaches taken in telemedicine. Telemedicine guidelines have been established for mental health⁵⁷ and should be applied to the virtual world. Through the evaluation of existing standards and our experience in this area, we have identified and summarized preliminary practice guidelines for mental health treatment through desktop VE applications.

Footnotes

Acknowledgments

The authors would like to acknowledge the many contributions of Randy Hinrichs and Janice Cowsert, especially their expertise in virtual worlds, three-dimensional learning, and the synergy of the countless imagination sessions that resulted in the T2 Virtual PTSD Experience as it exists today.

Disclosure Statement

No competing financial interests exist.

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