Ebook: Virtual Environments in Clinical Psychology and Neuroscience

Scientific discovery is a form of problem solving, and... the processes whereby science is carried on can be explained in the terms that have been used to explain the processes of problem solving. Simon, 1 966

We are entering the second wave of virtual reality (VR) applications in medicine. Surgical simulations and training, three-dimensional anatomy, and the new field of real time three-dimensional physiological imaging are some of the more notable uses and applications of VR in the first wave in clinical medicine. Because first wave applications required and continue to require significant Computing power, many of the Silicon Graphics and workstation-based technologies were well-suited to meet these demands. Until recently, the application of VR technology in mental health was severely limited by the lack of inexpensive, easy-to-maintain and easy-to-use personal-computer (PC) based Systems. The very expensive and high-powered computational systems are out of the reach of most practicing mental health professionals. The development of PC-based VR platforms with more user-friendly programming software is helping to launch this great second wave.

Two successful areas of VR application in psychology include treatment of specific phobias (such as fear of heights, fear of flying, fear of driving, fear of public speaking, and claustrophobia, etc.) and neuro-psychological evaluation and testing. Well over one hundred publications from at least fifteen centers around the world addressing these two areas are in the literature. Early results seem to indicate that virtual environments are not only effective but have multiple advantages over conventional therapies in the treatment of specific phobias. In addition it seems to make intuitive sense that this application will work. Before a wider acceptance of this new technology occurs however it is crucial that clinical trials and comparison of outcomes are published and are evaluated by peer-reviewed groups.

Neuro-psychological evaluation and testing is another area that can easily be transitioned to a virtual environment. Again, multiple advantages seen by performing these tasks in virtual environments are suggested. Clearly the three-dimensional testing would seem a better predictor of function in our three-dimensional world. Smaller numbers of studies are seen in a much wider area of mental health testing, evaluation, and delivery as demonstrated by the excellent work in this current volume.

It is now the time to continue exploring additional applications of this exciting technology. Several barriers remain however. The PC-based system, while inexpensive and easy-to-use, still suffers from a lack of flexibility and capabilities necessary to individualize environments for each patient. There is a question as to whether the admittedly more cartoonish graphies have wide acceptance by patients. On the other hand, in those circumstances the clinical skills of the therapist remain the most important factor in the successful use of VR systems. It is clear that building new and additional virtual environments is important so therapists will continue to investigate applying these in their day-to-day clinical practice. Possible scenarios for success could involve multi-disciplinary teams of engineers, computer programmers, and therapists working in concert to attack specific clinical problems. Information on advances in VR technology must be made available to the mental health Community in a format that is easy-to-understand and invites participation. For example, an inexpensive System that would allow the therapist and patient to enter the VR world together provides a basis for a number of interesting potential therapeutic interactions. It is important that the technical-oriented members of the team understand the aims, requirements, and scope of the therapeutic intervention so they may effectively bring advanced Computing tools that specifically address the problem. Future potential applications of VR are really only limited by the imaginations of talented individuals. The second wave is expanding rapidly, and the international community has already provided the basis upon which continued growth and development will occur. It is hoped that by bringing together this community of experts further stimulation of interest from granting agencies is accelerated.

Mark D. Wiederhold, M.D., Ph.D.

Editor-in-Chief CyberPsychology and Behavior La Jolla, CA, USA

This report provides a short survey of the field of virtual reality, highlighting application domains, technological requirements, and currently available solutions. The report is organized as follows: section 1 presents the background and motivation of virtual environment research and identifies typical application domain, section 2 discusses the characteristics a virtual reality system must have in order to exploit the perceptual and spatial skills of users, section 3 surveys current input/output devices for virtual reality, section 4 surveys current software approaches to support the création of virtual reality systems, and section 5 summarizes the report.

In order for Virtual Environments (VE) to be efficiently developed in the areas of clinical psychology and neuropsychology, a number of basic theoretical and pragmatic issues need to be considered. The current status of VE’s in these fields, while provocative, is limited by the small number of controlled studies that have been reported which apply this technology to clinical populations. This is to be expected considering it's relatively recent development, expense, and the lack of familiarity with the technology by mainstream researchers in these fields. In spite of this, some work has emerged which can begin to provide a basic foundation of knowledge which could be usefiil for guiding future research efforts. Although much of the work does not involve the use of fully immersive head mounted displays (HMD's), studies reporting PC-based flatscreen approaches are providing valuable information on issues necessary for the reasonable and measured development of VE/mental health applications. In light of this, the following review will focus on basic issues that we see as important for the development of both HMD and non-HMD VE applications for clinical psychology, neuropsychological assessment, and cognitive rehabilitation. These basic issues are discussed in terms of decision-making for choosing to develop and apply a VE for a mental health application. The chapter covers the issues involved with choosing a VE approach over already existing methods, deciding on the “fit” between a VE approach and the clinical population, level of presence, navigation factors, side effects, generalization, and general methodological and data analysis concerns.

Two interactive virtual reality environments were used to identify factors that may affect, or be affected by, the degree of immersion in a virtual world. In particular, the level of stress in a “swimming with dolphins” simulation is measured, as is the degree of simulator sickness resulting form a virtual roller coaster.

Analysis of the results indicates that a relationship between the degree of immersion and the following factors: excitement, comfort, quality and age. The following factors are found to depend on the degree of immersion: simulator sickness, control, excitement and desire to repeat the experience.

The effects of varying levels of immersion in virtual reality environments on participant's heart rate, respiration rate, peripheral skin temperature, and skin resistance levels were examined. Subjective reports of presence were also noted. Participants were presented with a virtual environment of an airplane flight both as seen from a two-dimensional computer screen and as seen from within a head-mounted display. Subjects were randomly assigned to different order of conditions presented, but all subjects received both conditions. Differences between the non-phobics' physiological responses and the phobic's response when placed in a virtual environment related to the phobia were noted. Also noted were changes in physiology based on degree of immersion.

Virtual Reality (VR) environments have significant potential as a tool in mental health research, but are limited by technical factors and by mental health research factors. Technical difficulties include cost and complexity of virtual environment creation. Mental health research difficulties include current inadequacy of standards to specify needed details for virtual environment design. Technical difficulties are disappearing with technological advances, but the mental health research difficulties will take a concerted effort to overcome. Some of this effort will need to be directed at the formation of collaborative projects and standards for how such collaborations should proceed.

The great potential offered by Virtual Reality (VR) derives prevalently from the central role, in psychotherapy, occupied by the imagination and by memory. These two elements, which are fundamental in the life of every one of us, present absolute and relative limits to individual potential. Thanks to virtual experiences, it is possible to transcend these limits. The re-created world may at times be more vivid and real than the one that most subjects are able to describe through their own imagination and through their own memory. This chapter focuses on imaginative techniques to find new ways of applications in therapy. In particular the chapter analyses in which way VR can be used to improve the efficacy of current techniques. VR produces a change with respect to the traditional relationship between client and therapist. The new configuration of this relationship is based on the awareness of being more skilled in the difficult operations of recovery of past experiences, through the memory, and of foreseeing of future experiences, through the imagination. At the same time, the subject undergoing treatment perceives the advantage of being able to re-create and use a real experiential world within the walls of the clinical office of his own therapist.

Virtual Reality (VR) is a new technology halfway between television and computer. It constitutes another step in the evolution of our use of a tool that allows us to see, to hear and to feel in a world created graphically in three dimensions, and to interact with it. VR is, mainly, a mental experience which makes the user believe that “he is there”, that he is present in the virtual worid. With this new tool, the user is no longer a mere observer of that which is happening on a screen, but he “feels” that he is immersed in that world and participates in it, in spite of the fact that they are spaces and objects that only exist in the memory of the computer and in the user's mind.

This chapter seeks to carry out different reflections at different levels. First, we will analyze the relationships between VR and Psychology, one of the disciplines that has made more efforts in order to understand how we obtain knowledge from the world and from ourselves. We will also analyze the impact VR can have in one of the applied disciplines of Psychology, which is Clinical Psychology. With regard to this application environment, VR becomes a tool which can generate useful models for Psychology (both normal and abnormal), and it is offered as a research context for Clinical Psychology; as a “realistic” laboratory where we can study behaviours, emotions, thoughts, etc; and a new means to develop psychological treatments.

The possibility of applying Virtual Reality (VR) techniques to the mental care of patients is discussed in this chapter. VR technology holds much promise for providing supportive activities and promoting cooperation among caregivers. Interactivity with media may give the feeling of control to patients and thus provide a greater joy than passively watching television. Immersion in VR is expected to reduce pain and relieve anxieties for a while. Some kinds of VR content would make patients relaxed or encourage them in their fight against disease. Moreover, networked VR could offer a virtual space where patients meet, communicate, organize activities, and share experiences with other people - other patients, friends, family members, medical doctors, social workers, and so on. A basic study and trials to evaluate our developed VR system, called the ‘Bedside Wellness System,’ provide evidence for the effectiveness of this approach. Future research tasks are also discussed.

This paper presents an overview of the development of the Learning in Virtual Environments programme (LIVE), carried out in special education over the last four years. It is more precisely a project chronology, so that the reader can sense the historical development of the programme rather than giving emphasis to any one particular feature or breakthrough, which are covered in other papers and available through the authors.

The project conception in a special school in Nottingham is followed by a description of the development of experiential and communicational virtual learning environments. These are followed, in turn, by the results of our testing programmes which show that experience gained in a virtual environment can transfer to the real world and that their use can encourage self-directed activity in students with severe learning difficulties. Also included is a discussion of the role of virtual leaming environments (VLEs) in special education and of its attributes in the context of contemporary educational theory.

Virtual Reality (VR) entered the mental health field some years ago. While the technology itself has been available for more than ten years now, there is still a certain amount of uncertainty among researchers and users as to whether VR will one day fulfill all it's promises.

In this chapter we are giving an overview of the Implementation of the technology in our mental health research facility in Basel, Switzerland. The development of two applications for use with claustrophobie and acrophobic patients perspectively serves just as an example within this context. Some may say, the chapter is too much based on technical considerations. Strictly speaking, VR is pure technology, even knowing that this special form of technology has sensory, psychological and even philosophical implications not known from other human computer interfaces so far. As far as we are concerned, the development of the technology for use within the mental health sector has merely just begun. As today's mostly used immersive output devices (Head-mounted Displays, shutter glasses) do not have a satisfactory resolution, do restrict movements and prevent multi-user-capabilities, there will be a soar of mental health applications the day some or at least the most important of these obstacles have been overcome.

Behavioral therapy techniques for treating phobias often includes graded exposure of the patient to anxiety-producing stimuli (Systematic Desensitization). However, in utilizing systematic desensitization, research reviews demonstrate that many patients appear to have difficulty in applying imaginative techniques.

This chapter describes the Virtual Reality Therapy (VRT), a new therapeutical approach that can be used to overcome some of the difficulties inherent in the traditional treatment of phobias. VRT, like current imaginal and in vivo modalities, can generate stimuli that could be utilized in desensitization therapy. Like systematic desensitization therapy, VRT can provide stimuli for patients who have difficulty in imagining scenes and/or are too phobie to experience real situations.

As far as we know, the idea of using virtual reality technology to combat psychological disorders was first conceived within the Human-Computer Interaction Group at Clark Atlanta University in November 1992. Since then, we have successfully conducted the first known pilot experiments in the use of virtual reality technologies in the treatment of specific phobias: fear of flying, fear of heights, fear of being in certain situations (such as a dark bam, an enclosed bridge over a river, and in the presence of an animal [a black cat] in a dark room), and fear of public speaking. The results of these experiments are described.

Even if there has been significant progress in research on eating disorders, little empirical work has been done yet to specify the content of clinical guidelines and to validate their efficacy in treatment. In particular there are at least three themes that are somehow neglected by current guidelines: body experience disturbances, motivation for change and the integration between the different approaches used.

This chapter details the characteristics of the Experiential Cognitive Therapy (ECT), an integrated approach ranging from cognitive-behavioral therapy to virtual reality (VR) sessions. In particular, using VR, ECT is able to address both body experience disturbances and motivation for change. In the chapter a description of all the phases of this approach are offered by using an actual clinical case: a 22-year old female anorectic patient.

The use of psycho-dynamic psychotherapy integrating virtual reality (VR) dealt with in this study on the treatment of erection dysfunctions and premature ejaculation started several years ago, after having seen the scarce results we obtained using exclusively a psycho-dynamic approach (accompanied by pre-recorded sound and music). Considering the particular way that full-immersion VR involves the subject who experiences it, we hypothesized that better results could be obtained during therapy for these sexual disorders and in particular regarding the nature of erection dysfunction, commonly referred to as impotence “a persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate erection.” The plan for therapy consisted of 12 hour-long sessions over a 25-week period, and the methods involved the use of a VR helmet, joystick and miniature television sereens that projected specially-designed CD-ROM programs on psychological development.

The technology of virtual reality (VR) offers several advantages in the field of medicine because it enables us to practice medical procedures repeatedly, and can provide a variety of experiences by using virtual organs in different patients. It also aids in leaming about a clinical procedure and facilitates objective evaluation by a Supervisor.

In the field of clinical oncology, a virtual environment can be useful for simulating surgery, diagnosing cancer invasion, obtaining informed consent or enhancing patient education, and for clinical communication using network-based VR. This technology can also be used to improve a patient's living conditions and to treat the psychological problems and/or stress of cancer patients. In the present chapter advanced VR research for palliative medicine at the National Cancer Center Hospital Japan is described and discussed.

Virtual environments can create a relaxed mood, increasing a patient's receptivity to leaming. Personal stories and an individual approach to the content, rather than abstract facts, make the CD-generated experience vivid and informative. With the user in control, selecting content and interacting constantly with the program, the virtual experience is more meaningful than the one created by simply retrieving information. This chapter explains how three CD-ROMs containing cancer information - Breast Cancer Lighthouse, Easing Cancer Pain and Cancer Prevention Park - embody personal stories and medical information in virtual environments.

Technological advances, including the use of virtual reality, have contributed enormously to improving the treatment, training, and quality of life of children with disabilities. This paper describes the advantages of VR for children with disabilities, how VR can minimize the effects of a disability, the role of VR in training and skills enhancement, and how social participation and the child's quality of life may be improved through the use of VR.

Examples from published literature and Internet sites are given of current and completed projects which focus on improving the lives of children with disabilities. The research describing the efficacy of knowledge and skills transfer from a virtual environment to the real world are examined in relation to children with disabilities. Finally, the current limitations and future directions of VR for children with disabilities are considered.

This chapter outlines the use in psychotherapy and medical diagnosis of an intelligent software system that helps clients to explore Personal Myth within virtual reality environments. Patented MYTHSEEKER software will allow clients to work with mythic analogues of lifeshapes and aspirations. This can help to focus therapy directions, find ways to participate with the person's world, and allow a kind of personal expression not previously possible. The software phases of assessment, facilitation, and enaction are described by which the client is assisted to explore systems of mythology or spirituality (called Depth Systems) that are traditional, ancient or newly-arising. The client builds a Personal Depth System representing Personal Myth, based on experiencing other Depth Systems, which can itself be experienced in the virtual environment This paper outlines our methodology and technology to realize these operations. Space limitations prevent further description in the present chapter of MYTHSEEKER software technology or psychotherapy scenarios of involvement.

Primary efforts to create virtual humans have been in the production of computer generated ergonomically correct objects that look like humans. Although there has been concern with essential human factors, absent are the metrics of human relatedness, or the ability to assess the degree to which a virtual human elicits human emotions. We discuss the potential application of attachment theory as a context for the development of such an assessment paradigm, and specifically the application of the Ainsworth Strange Situation in the evaluation of a “Virtual Mom”. Virtual relatedness fidelity is discussed as a macrometric to define relatedness that would occur with virtual humans. Potential lessons learned are discussed as they apply to the selection of those to develop the model, and its impact on the introduction of virtual humans into clinical psychiatry and psychology.

Some research projects have begun to test the possibility of using Virtual Environments (VEs) for research in neuroscience, neurosurgery and for the study and rehabilitation of human cognitive and functional activities. In fact, VEs let users navigate and interact with computer-generated 3-D environments in real time, allowing for the control of complex stimulus presentations. VEs enable the neuroscientist to present a wide variety of controlled Stimuli and to measure and monitor a wide variety of responses made by the user.

This paper highlights recent and ongoing research related to the applications of VEs in the neuroscience arena. In particular it focuses on the European and US applications in this field.

This chapter presents an augmented-reality based therapeutic device designed to overcome gait problems associated with Parkinson’s Disease (PD). A normal model of gait is proposed followed by a model of Parkinsonian gait with the goal of construction of a gait enabling therapeutic device. The fondamental underlying tenet of the model is that vision pathology is responsible for the majority of Parkinsonian gait pathology. The basis for such a claim is the well documented phenomenon known as Kinesia Paradoxa, whereby in the presence of certain so-called visual cues a PD subject can be transformed from a totally immobile, helpless victim of this disease into a near normal walking individual. Several gait-enabling devices are also described.

Spinal cord injuries (SCIs) have a profound physical, social and emotional cost to patients and their families. Obviously SCIs severely disrupt normal patterns of interaction with the environment. Firstly, the opportunities for active interaction are inevitably diminished due to motor or sensory impairment. Moreover, such problems may increase as the time since injury lengthens and the patient becomes more withdrawn and isolated in all spheres of activity. However, advances in Information Technology are providing new opportunities for rehabilitation technology. These advances are helping people to overcome the physical limitations affecting their mobility or their ability to hear, see or speak.

In this chapter an overview is given of the design issues of a VR-enhanced orthopaedic appliance to be used in SCI rehabilitation. The basis for this approach is that physical therapy and motivation are crucial for maintaining flexibility and muscle strength and for reorganizing the nervous system after SCIs. First some design considerations are described and an outline of aims which the tool should pursue given. Finally, the design issues are described focusing both on the development of a test-bed rehabilitation device and on the description of a preliminary study detailing the use of the device with a long-term SCI patient.