For 100 years, our primary therapeutic tools have been words, buttressed by the other low-tech features of everyday human communication: facial expressions and body language. But then came the pesky tech revolution, replete with all those computers and apps that have come to supplant and enhance face-to-face connection. As a rule, however, therapists don’t like to change too quickly, and so far they’ve been slow to incorporate this new technology into their clinical work.
Enter Skip Rizzo, a brash, tech-savvy psychologist, who’s spent much of his career developing methods for helping clients overcome severe emotional difficulties by returning to the scene of their trauma via technology. As director of medical virtual reality at the University of Southern California’s Institute for Creative Technologies, a partner of the Department of Defense, Rizzo has taken standard exposure therapy in a new direction by helping veterans achieve emotional resolution by recreating the sights and sounds of their trauma. As he puts it, “We can now build digital Skinner boxes that immerse people in experiences that can help them heal.” In the conversation that follows, he explains how this therapeutic application of virtual reality (VR) works.
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RH: What drew you to applying VR in your work in the first place?
RIZZO: It started when I was working as a psychologist in traumatic brain injury (TBI) rehabilitation. One of the challenges with TBI clients is maintaining motivation and attention, especially when somebody has the kind of frontal lobe injury that’s quite common in car accidents. One day I came across one of my TBI clients, who ordinarily had a hard time concentrating, sitting under a tree during break time, glued to a small gadget in his hand. This was in the early 1990s, and it was the first time I’d seen someone using a Game Boy. I just stood there and observed his focus for 10 minutes and said to myself, There must be some way to translate this kind of intense involvement beyond Tetris into something with a bit more therapeutic benefit.
At that time, I’d just gotten a Nintendo NES system at home with a game called SimCity. Playing this game requires a lot of executive functioning. You have to come up with a plan, initiate it, monitor outcomes, and initiate repair strategies. Anybody who’s ever played SimCity knows what I mean. At that moment, I knew we could leverage this kind of digital game activity to motivate engagement with rehabilitative tasks.
RH: So you quickly saw the potential value of video games in rehabilitation?
RIZZO: Yes, and around the same time I also heard about VR. I’d heard an NPR report about a department store in Japan where people could put on a VR headset and use data gloves to immerse themselves in a virtual kitchen and select appliances with various features and colors, arrange them, and then hit a button to get them ordered, delivered, and installed. As I listened to that, I thought that kind of VR environment could bring together drill-and-practice restorative methods used in cognitive rehab, with the added feature of helping people train in an endless range of relevant learning environments that could be customized to integrate restorative training with functional practice. Since the technology to do this at the time was costly and complex, I took a postdoc position where I’d have access to computer programmers in the computer science department and could build a clinical VR lab.
From that time until 2003, I mainly developed cognitive VR systems, but after the start of the Iraq War I began to think about how to use this new digital technology to deliver prolonged exposure therapy for PTSD. Sure enough, by 2004 we’d developed some VR prototypes and got funding from the Office of Naval Research to further our work, and over the last 11 years we’ve evolved the system to address combat-related PTSD and now military sexual trauma as well.
RH: If you had a veteran coming in with PTSD, how would you use this VR technology?
RIZZO: The model we use is the 10-session, traditional evidence-based protocol of prolonged exposure therapy. The first few sessions are spent getting to know the client, not just throwing them into VR. It’s all the rapport building and history-taking that you’d do in normal therapy. It’s only in session four that you actually bring in the VR. Then, instead of closing their eyes and recounting their traumatic experience, they put on the headset and, with the help of the clinician, choose from 14 different wartime environments that have been programmed in: the Afghan village, the Iraqi marketplace, the forward operating base in the mountains, whatever. They select the one that matches to some degree their experience during their deployment. They adjust the time of day, the lighting, the ambience sounds in the setting. The clinician controls all this and creates a virtual experience that’s customized to the client’s individual trauma narrative.
Then the client begins to narrate his experience. “We’re driving down the roadway in a Humvee. I’m in the passenger’s seat. My best friend is driving. I feel a little funny as we’re approaching this village. Then all of a sudden, that IED goes off. I walk away from the blast, and my best friend dies.” That might be one initial cycle of the exposure. Meanwhile, the clinician is operating what we call the Wizard of Oz Controller to make those things happen, mimicking in real time what the client is talking about.
In that first cycle, you typically hear a thoroughly cognitive, sanitized description of the trauma experience. Once that’s done, the therapist typically says, “Okay, let’s go back and take it from the beginning. It’s now 15 minutes before, tell me a little bit about your friend.” This time, the therapist wants to elicit more emotion, bearing in mind that prolonged exposure is a challenging approach to treatment—hard medicine for a hard problem. Of course, a lot of people aren’t so fond of prolonged exposure because they believe that there’s a risk of retraumatizing the client, but in the hands of a well-trained clinician thoughtfully pacing the exposure, that doesn’t happen, and prolonged exposure is generally agreed to be an evidence-based approach with a lot of research support. So you go back and get the person describing sitting with his friend in the Humvee. The clinician strategically asks questions or prompts things. Eventually, you get to that point the emotions begin to bubble up and can be processed.
RH: Are they on heart-rate monitors?
RIZZO: Yes, in many cases, clinicians monitor the client’s psychophysiological state. That’s important because the client may feel like they’re in control, but their heart-rate is skyrocketing. So the clinician is going to see that and back off and say, “Let’s process a little bit.” You go through these repeated cycles, and when you start to see the emotion really bubbling up, you say “Let’s try it for just a little bit longer.” You want to help them confront and process the trauma experience and get over that hump of avoidance. Avoidance is what perpetuates the whole thing.
RH: How so?
RIZZO: When you avoid something you fear or that makes you anxious, you get a temporary sense of relief, but that reinforces continued avoidance and perpetuates the disorder. When you reinforce avoidance, it can start to generalize to anything that resembles the trauma. If you can get people in a safe environment to confront and process these difficult emotional memories, eventually you see extinction learning take place and the anxiety not rising to the same peak. Over time, it dissipates more and more quickly. Once you’ve gone through one traumatic memory, then you can then move on to the next if it’s relevant to the client’s needs.
As you go along, you may even import customized ambient sounds from a sound library. Some clients may say, “The radio went wild. We were getting all kinds of calls,” and the clinician might recreate those sounds in real time within the simulation.
RH: You can recreate that whole scene?
RIZZO: You have 14 different, quite expansive wartime environments to choose from, with different nooks and crannies in each one. There’s the slum area, the mosque area, the Afghan rural village, and so on. You click and you’re up on a roof. Click again and you’re up on a hillside by a mass grave. Click again and you’re by a river. Once a clinician gets to know the available environments, they can help clients find one that resembles the context of their story.
RH: Are you teaching the clients relaxation at the same time?
RIZZO: You teach them deep breathing in the beginning as a stress-management tactic. Most of all, you want to circumvent avoidance, but you want to do it in a supportive and encouraging fashion. If they’re having a really hard time but you think they need to keep going, you’re going to encourage deep breathing, but keep them engaged with the trauma narrative.
RH: What do you find after 10 sessions?
RIZZO: So far, in three or four studies, VR is at least as good as traditional exposure—and in some cases, it’s better. As I see it now, VR may not be for everybody, but it may break down barriers to care for certain populations that otherwise might not seek help. Perhaps it’s more appealing to digital-generation service members and veterans, who grew up with the technology and are familiar with it. We have the evidence to show that. And in the end, it comes down to providing clients with a variety of options to choose from to help them engage in this form of trauma-focused treatment that aims to help them address, rather than avoid, processing these difficult emotional experiences.
RH: What do you see in the future for VR and therapy?
RIZZO: Clinical VR applications have been developed for pain distraction with acute pain, like daily severe burn-wound care. We’re also going to see more use of VR in the cognitive assessment area, and in the area of physical rehabilitation to help stroke patients physically engage in game-based rehabilitation. But the biggest growth area I see is with artificially intelligent virtual human agents, characters that you can interact with to develop interpersonal skills or to practice how your thinking might modulate your emotions in a provocative context.
RH: Aha! This is what raises fear in of a lot of clinicians. Are you saying there’s a possibility we could lose our jobs to virtual-human-agent therapists some day?
RIZZO: Don’t worry! Artificially intelligent virtual humans aren’t replacements for clinicians. We’re not in the business of putting clinicians out of a job: just trying to give them tools to do their job better. And to fill the gaps where there will never be a clinician available, 24/7.
RH: What are some other applications?
RIZZO: Imagine that clients with family issues might put a low-cost, 360-degree spherical camera in the middle of the Thanksgiving dinner table and capture a whole set of interactions going on. Then they could upload it to a smartphone and use a $99 VR headset. Afterward, a therapist could help them look at the dynamics of the family interaction and their roles in what’s going on. As a therapist, you wouldn’t have to rely exclusively on the client’s recollection and their capacity to observe things accurately. Or you could create virtual versions of standard presenting problems, like the work environment with the angry boss, or the family environment with the domineering spouse to provide role-play practice in assertive vs. aggressive responding. Or you could help a client explore a VR version of their experience growing up in an abusive environment when their dad was coming home and everybody was running for the closets. Also, we now have a system that allows for virtual clients to be created to give novice therapists the chance to practice their clinical skills well before they get their hands on a live client.
While previously hamstrung by costs, VR technology is charging forward in the consumer marketplace. In the next few years, a VR device will probably be like a toaster—although you may not use it every day, every household will have one. In fact, many clinicians have come to recognize its potential for creating tools that can amplify and extend their capacity to deliver evidence-based care.
But in the end, VR is just a technology. The question is how we apply good clinical principles to implement it in the best possible way. You want to get clients into a space where they can best address whatever their issues are, and that applies across the board. Whether you’re a behaviorally oriented person or a psychodynamic or humanistic one, the technology is just a tool that if used thoughtfully can amplify and extend your skills. But it’s not a replacement for good therapy conducted by a qualified clinician.
Ryan Howes
Ryan Howes, Ph.D., ABPP is a Pasadena, California-based psychologist, musician, and author of the “Mental Health Journal for Men.” Learn more at ryanhowes.net.
