Bringing the Battlefield Home: How VR is Shaping the Future of PTSD Care
For many of us, VR means exploring fun new worlds with Oculus Rift or Google Cardboard, as opposed to other more emotional and challenging experiences. After reading about VBI, and the success of Brave Mind, I wanted to know more about this organization and their process. I was able to interview Dr. Marat V. Zanov, a psychologist at VBI and former member of the Air Force, to ask more about his company and Brave Mind.
How did the founders originally get the idea to combine their skills and form this organization?
Our founders, Barbara Rothbaum and Larry Hodges, had known each other before the creation of VBI. They put together their thoughts and combined their skills of clinical psychology and computer programming to create VBI. They wanted to run a study on the fear of heights. It was a small sample size, but still extremely successful. The project actually lead to the fear of flying application. This project is still in use today and very, very successful.
Where do ideas for new VR therapies come from?
While we don’t develop new therapies, we do develop applications for clinical treatment and approaches. We develop tools, cool tools, high tech, cutting edge tools that are based on empirically supported treatment. For example, prolonged exposure therapy has been well-documented and supported to treat anxiety disorders. We understand this and don’t modify these therapies. We develop technological tools to adopt these approaches for clinical practice.
The ideas behind the tools we create are driven by the current needs of clinicians and researchers. For the latter, it is often driven by what kind of funding is available. For example, if childhood obesity research is of interest to the government, they will allocate funding for it. Researchers will then apply for funding and want to develop tools to run research on childhood obesity. We are currently engaged in the collaboration with at least one researcher who is interested in obesity. We are creating the virtual assets for their study.
For clinicians, it’s slightly different. Their ideas are driven based on need. In the clinical realm, it’s easy to determine which disorders are in need of tools. We are clinical psychologists first, and we know what the needs are out there. We also know the prevalence of the disorders we treat. We aren't going to develop a tool that would address something for a very small segment of the clinical population. We tailor our applications to treating most frequently occurring disorders.
How do the technicians and clinicians collaborate together? How involved are clinicians in making these virtual worlds?
We are in a very unique position where we combine this art of creative, virtual, otherwise technological solutions and clinical research. We work collaboratively on developing research applications daily. Every step of the development process is guided by the clinical psychologist who is designated to be the primary investigator(PI) of that project. While I am the only full-time clinical psychologist on site, we have four other clinical psychologists who act as PI's on various projects. Just because we are a technological company doesn't mean we are just going for cool looking graphics. There is a reason why we have psychologists on site. They ensure whatever we develop is based on empirical evidence and support. Of course, the technicians tell us if something is or isn’t possible, but that's just a give-and-take process. As a result, really cool applications get developed.
As a former member of the Air Force, and a clinical psychologist, were you involved in creating Brave Mind?
I didn’t play any part in the creation of Brave Mind. I came to VBI in 2014 and Brave Mind was in existence for quite a few years by then. The development was funded by the Office of Naval Research, Telemedicine Research and other organizations. I know that to some extent we consulted the University of California, my alma mater. We also consulted veterans as to the realism and appearance of the virtual assets such as the environment and the weapons. I wasn't one of those veterans.
As a former member of the service, can you say how real it is?
Realism is a relative notion here. Since we are developing clinical products, they are being perceived by individuals with a particular phobia, fear or disorder. For you and I, sitting in a virtual plane may not feel like it is doing anything to you. I play video games at home. I can tell that some of my video games are more realistic than the software we have here. The software we have here is really, really, high quality and very, very, good. Nevertheless, let's say Sony develops a video game and spends $300 million developing it. Of course, they're going to have awesome graphics. If I sit down in a virtual airplane, I'll think to myself, “maybe it’s not as realistic as it could've been.” However, if this particular environment or this particular stimulus causes fear for the person experiencing it, they would completely look at the situation in a different perspective. The video actually reminds them of flying. So our experience would be different from that person.
With that being said, Brave Mind is pretty realistic. I don’t know if I have PTSD or not, so my experience is a little different from someone who does. From what I’ve seen, the virtual Iraq and Afghanistan look close to the surroundings of the areas that I’ve been too. The inside of the Humvee is very accurate. I had the same weapons they use in the video and everything looks the same. The cool thing about this tool is it comes with a vibrotactile platform. Let’s say you're on foot patrol or a convoy, you can feel the explosions in your entire body. We also have a scent machine, so at the appropriate time in your narrative, we can turn on a scent such as gunpowder, fuel, burning rubber, etc. It’s very realistic. It delivers a “"quadrosensoral” experience. There I just came up with a new word(chuckles). We introduce four senses; auditory, visual, vibrotactile and olfactory(smell).
Being so realistic, how effective can VR be in treating PTSD?
From a clinical standpoint, exposure therapy has been proven to be quite effective. There are tons of well-controlled studies that show it reduces symptoms. It is based on prolonged exposure protocol. Basically, it holds that symptoms of PTSD develop as a result of avoidance of trauma-related cognitions and situations that remind you of it. In prolonged exposure or VR, we help that individual interrupt the cycle and correct the thinking that causes cognitive and behavioral avoidance. We do this for in vivo and VR exposures. That's the beauty of virtual reality exposure; it combines both in vivo, which is exposure in real life, and gradual exposure, which is done systematically on a repeated basis over and over again. As a result, the person's emotional, dysfunctional cognitive and behavioral response to those triggers decrease, and eventually these reminders will lose their strength and their ability to disrupt an individual's life.
There are no studies, at least as far as my reading goes, showing VR is more effective than usual treatments. However, it is more practical and cost effective. There’s no way you can take a veteran back to Afghanistan. We still have ongoing operations there. There’s no way we can place them in that situation and expose them over and over again. With VR, it’s possible. You don’t have to pay for airfare or need constant access to have repeated exposures. All it takes is just a push of a button. The great thing about VR is that we can control the amount of exposure as well. We are doing this literally in the office. We can tailor the therapy for the specific patient without this “drinking from the fire hydrant” effect.
Do you know how the scenes were selected?
I don't know the specifics, but I imagine that Brave Mind creators polled the veterans and found out what were the most frequently encountered situations. It doesn't take too much guessing to figure out: foot patrols, convoys, and attacks. There’s only so much you can do. What’s interesting is they made permutations of the various situations. The actual number of potential scenarios in Brave Mind is difficult to calculate, because even though they have about 11 different scenarios within each, you can create so many different permutations. It’s a pretty versatile program.
What parts do clinicians play when patients are using these applications?
The first step for the clinician is to help set goals and track progress. We need to be clear with the patient as to what it is we are doing and why we are doing this, and be very clear about what it is we are trying to achieve. Second, of course, is to provide psychoeducation. We need to describe the elements of this disorder, identify the symptoms and describe the mechanism of change. That is the mechanism that will improve the symptoms. We also teach skills such as breathing and relaxation methods.
While the treatment is taking place, we guide them through the emotional processing, which is the modification of memory structures that underlie one's emotions. Some of this treatment can be done at home. We also provide homework assignments that help them strengthen their coping mechanisms. Other parts have to be carried out alongside a psychologist or therapist. People need the structure and guidance. In the case of VR Exposure Therapy for PTSD, it is manualized. Meaning, there are steps they have to cover during the process. While manuals are not set in stone, they provide guidance on generally effective methodology. There have been numerous studies done on the best ways of doing prolonged exposure therapy which we try to follow.
So someone couldn’t do this at home with something like Google Cardboard?
Most products we have right now are designed to be clinical tools. They are tools to be used by licensed medical providers who are trained for this particular therapy type. We are currently developing several self-help tools. These tools can actually be used at home. They are a bit more intensive. In terms of development, we need to combine research and best practices of conducting therapy. We need to package it in a way where the patient feels as though the clinician is at their side. There will always be a sample or subsample of the population that will need the help of a psychologist, but making a clinically sound product for self-help is not impossible, and we are very invested in developing them.
Where do you see this technology heading in the future?
Obviously, we are talking about more affordable and portable. In terms of VR, I think it will become more immersive and a greater interaction with the virtual environment. Maybe through tactile feedback as well as spatial or three-dimensional audio.
Then, of course, artificial intelligence(AI) will continue to get better and better. It’s here now and has been around for a while. The thing with AI is it improves with time. It's not exactly a fully self-learning process, but it's getting there. I think the wave of the future is the advancement of AI, and soon, the separation between human-thinking and computer-thinking will become blurrier and blurrier. I believe all technology, not just VR, will become fully integrated into our daily experience.