Immersed in a Virtual World Researchers using virtual reality technology for therapy and other applications. By Jane M. Sanders

IN TODAY'S AGE of cyberspace, it may not surprise some that people with mental health problems are finding help in a virtual world.

photo by Gary Meek Fear of public speaking is one of several phobias that clinicians can treat with virtual reality therapy. Virtual environments created by Georgia Tech and Emory University researchers are being used at psychologists' offices in Atlanta and 12 other locations nationwide. (300-dpi JPEG version - 202k)

But it was a decade ago when Larry Hodges first envisioned the potential of a computer-generated virtual world for treating people with anxiety disorders. Today Hodges, a professor in the Georgia Institute of Technology College of Computing, is enjoying academic and business success with his collaborator Barbara Rothbaum, an Emory University psychiatry professor. Most important to them, they say, is helping real people deal with real problems in a virtual world.

photo by Gary Meek Larry Hodges, a Georgia Tech professor of computing, collaborated with Barbara Rothbaum, an Emory University professor of psychiatry, to create virtual environments to treat a variety of phobias, including the fear of flying.

"Virtual reality technology works well in treating a number of conditions," Hodges says. "We can use it when treatment is too difficult to handle logistically in reality, or it's too time consuming. Also, we ask whether it's too dangerous to treat something in a real environment."

For example, therapists have traditionally treated the fear of flying in an airplane by exposing the patient to a real aircraft and eventually a flight. Logistically, it is difficult to arrange such exposure. Emotionally, it is difficult on the patient because of potential embarrassment. So only a small percentage of people with a fear of flying have sought treatment.

But now the 15 million Americans who are afraid to fly may be more willing to undergo therapy. In the privacy and convenience of a therapist's office, they can face their fear on a virtual airplane – one of six virtual therapy environments created by Hodges and Rothbaum and marketed by their Atlanta company, Virtually Better Inc.

In a darkened treatment room, the patient wears a head-mounted display with earphones and separate screens for each eye. The display also includes a head-tracking device to provide location and orientation information to the therapist's computer in the room. The computer then provides visual images on the screen that are consistent with the direction in which the patient is looking in the virtual environment.

image courtesy of Larry Hodges The 15 million Americans who are afraid to fly may be more willing to undergo therapy now that a new kind of treatment is available. In the privacy and convenience of a therapist's office, they can face their fear on a virtual airplane created by Georgia Tech and Emory University researchers. Here is a view from the airplane's virtual window. (300-dpi JPEG version - 120k)

The patient is seated in an armchair on a low platform and buckled in with a seatbelt. The chair vibrates, similar to an airplane seat, as the virtual aircraft takes off and lands. The patient hears the roaring of the plane's engines as they accelerate. Looking out the window, the patient sees the skyline of Atlanta fade in the distance as the aircraft takes flight. The therapist assumes the role of pilot, and the patient hears his voice announcing the departure.

Though the virtual reality (VR) graphics are simple, they combine with the auditory and tactile stimuli to create an environment real enough to immerse patients in their surroundings.

"It gave me an impression of the environment of the airplane cabin and the window view," says Shannon, a 38-year-old who was successfully treated at Virtually Better in 1999. "At first I was disappointed that it was not more realistic. But then the chair began to vibrate, and I buckled the seatbelt.... So eventually the entire environment combined to set me up for a representative experience."

VR therapy promises to be an effective treatment, particularly for the fear of flying, the researchers say. Their controlled study of patients undergoing VR therapy for a fear of flying showed the virtual method works as well as traditional exposure therapy. The researchers reported their findings last year in the Journal of Consulting and Clinical Psychology.

Furthermore, patients seem to prefer virtual therapy over the traditional treatment, Hodges says. All but one of the control patients, who did not receive therapy during the study, later chose to undergo VR therapy instead of traditional exposure therapy.

"Over the course of treatment, my level of fear decreased from extreme to manageable," Shannon says. "I used the fear management techniques I learned in the first four sessions and then practiced them in the VR environment.... I started off doing badly, but I progressed dramatically over the course of the therapy."

image courtesy of Larry Hodges Gradual exposure to the view from several virtual bridges can help patients deal with a fear of heights. (300-dpi JPEG version - 386k)

Shannon loved to fly as a child, but then had a bad experience on a flight as an adult. She became disoriented and fearful as her airplane was forced to circle Atlanta's Hartsfield Airport in heavy clouds before it could get landing clearance. For the next eight years, she flew only when she absolutely had to do so; flying induced panic attacks. Now, after VR therapy, Shannon says she has rediscovered the fun of flying that she experienced as a child.

In addition to fear of flying, Virtually Better Inc. now offers VR therapy programs for fears of heights, storms and public speaking. VR therapy initially proved its effectiveness for treating fear of heights in 1993 when Hodges and Rothbaum conducted the first controlled study on the use of VR exposure for treating an anxiety disorder. They published their groundbreaking results in the April 1995 issue of the American Journal of Psychiatry.

Another effective VR therapy program licensed by Virtually Better is Virtual Vietnam, which treats veterans suffering from post-traumatic stress disorder. It continues to be successfully used at Veterans Administration hospitals in Atlanta and Boston.

Virtually Better operates a VR therapy clinic in metro Atlanta, and it has licensed its programs to 12 other clinical psychology practices across the United States. Therapists can install a complete system for $15,000. Treatment costs range from $100 to $200 a session, and the therapy usually requires seven to 15 office visits. Many insurance companies will cover the cost of VR therapy now because it is considered a form of the long-proven exposure therapy.

image courtesy of Larry Hodges VR therapy initially proved its effectiveness for treating the fear of heights in 1993 when Georgia Tech and Emory researchers conducted the first controlled study on the use of VR exposure for treating an anxiety disorder. Patients rode a virtual glass elevator to the top of the atrium in a virtual hotel. (300-dpi JPEG version - 167k)

"The need for VR therapies for anxiety disorders is large," Hodges says. He quotes statistics from the American Journal of Psychiatry and the U.S. Census that indicate more than 30 million Americans between the ages of 15 and 54 suffer from some type of anxiety disorder.

To meet the demand, researchers at Georgia Tech, Emory, Virtually Better and elsewhere are developing additional virtual environments for therapy and other purposes. Chris Shaw, a visiting senior research scientist at Georgia Tech, is developing a program for treating people with a fear of driving. Eventually, patients will wear a head-mounted display and hold onto a steering wheel and press gas and brake pedals. As they steer and accelerate or brake, they will first go through a virtual parking lot, then later a virtual highway.

Virtual environments can serve other purposes, as well. Emory University graduate student Jon Gershon, who works for Virtually Better, is studying the use of VR for pain distraction in pediatric cancer patients at Egleston Children's Hospital in Atlanta. In the privately funded study, patients undergoing catheterization for chemotherapy wear a head-mounted display and interact with a Georgia Tech and Zoo Atlanta educational VR program called Virtual Gorilla.

One patient consistently vomited in anticipation of the procedure; the only time she didn't throw up was when she was interacting with the Virtual Gorilla program, Hodges recalls.

"This is probably one of those things that will be difficult for a hospital administrator to show on the bottom line how VR for pain distraction saves them money," Hodges says. "The real value here is to the kids, the parents, and the nurses and doctors who treat them. It's hard to put a price tag on that. But this is an important part of what we do with VR.... I think eventually that hospitals will have these systems because private foundations and children's advocacy groups will provide them."

Researchers elsewhere are also beginning to use VR technology in assessment, diagnosis and physical rehabilitation. For example, researchers at the University of Southern California are creating a virtual environment to assess children for attention deficit hyperactivity disorder. Children will wear a head-mounted VR display depicting a virtual classroom. Clinicians can control the environment and more objectively analyze the patient's responses, Hodges says.

image courtesy of Larry Hodges Virtual Vietnam is a VR therapy program that treats war veterans suffering from post-traumatic stress disorder. Created by Georgia Tech and Emory University researchers, Virtual Vietnam is being used successfully used at Veterans Administration hospitals in Atlanta and Boston. (300-dpi JPEG version - 317k)

Another venue for VR technology is in training and evaluating employees. Shaw is creating a virtual house fire for the Atlanta Fire Department to train and evaluate officers for promotion. The virtual fire could help determine whether officers know how to fight a fire, manage people and keep firefighters as safe as possible on the scene, Shaw explains.

Also, the house fire scenario is especially important because officers in some areas – for example in the bustling highrise district of Midtown Atlanta – don't often fight this type of blaze.

"They want everybody to be exposed to all types of emergencies," Shaw says. ".... So we are developing scenarios in the program where officers can make good choices and not good choices. The simulation will allow opportunities for many choices to be made."

Still other applications for VR technology are in education, national defense, design and scientific visualization. Georgia Tech researchers are active in all of these areas.

VR technology has existed since the early 1970s, and it has come a long way, particularly because of advances in computing power. Still, there are many technical hurdles for researchers to jump. For example, it is limited by tactile feedback, hand-eye coordination and the creation of smell, Hodges says.

"VR barely works, but it is actually useful and cost-effective, particularly for therapy," Shaw says. "The cost for a VR system has dropped considerably. And 3D graphics are cheap now because of gaming applications.... So VR is starting to work in situations where you can't easily adjust reality."

As costs continue to decrease and the technology improves, and as more studies show success with VR therapy and other applications, VR technology will become more widely used, Hodges adds.

For more information, contact Larry Hodges, College of Computing, Georgia Tech, Atlanta, GA 30332-0280. (Telephone: 404-894-8787) (E-mail: hodges@cc.gatech.edu);    or Chris Shaw, same address. (Telephone: 404-894-6328) (E-mail: cdshaw@cc.gatech.edu);    or Barbara Rothbaum, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 1440 Clifton Road, Atlanta, GA, 30322. (Telephone: 404-778-5684) (E-mail: brothba@emory.edu);    or Virtually Better Inc., 2450 Lawrenceville Highway, Suite #101, Decatur, GA 30033. (Telephone: 404-634-3400) (Web site: www.virtuallybetter.com)

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Last updated: July 14, 2001