Welcome back to the UCF RESTORES Director’s Cut series, where we sit down with our center’s executive director Deborah Beidel, Ph.D., ABPP, to get her take on popular topics, current events and other developments shaping the national discourse around mental health and wellness.
Recently, The Wall Street Journal published an online feature – “Confronting Your Fears in Virtual Reality Therapy” – exploring the current state and future potential of virtual reality (VR) in medical and psychological treatment. Dr. Beidel joined leaders and innovators from around the globe to lead this conversation – and we’re taking the opportunity to dig in a bit further. Read on for more and click here for details on UCF RESTORES new, proprietary VR treatment tool.
To start us off, could you to please clarify the historical use of virtual reality in treatment at UCF RESTORES? Where did you start, where are you now, and how did that journey take shape?
I’m going to bring us back to the mid-1990’s, when I was working with veterans from the Vietnam War. Exposure therapy was the treatment of choice, but it was difficult because many veterans did not want to imagine the traumatic memories that they had tried to forget for 30+ years. And if they did imagine the traumatic event, they often had difficulty holding the image because of how anxiety-inducing remembering that event could be. So many researchers were seeking out how to improve exposure therapy, and virtual reality seemed to be a promising avenue.
Initially, VR was focused on what we call specific phobias – a fear of heights, flying, or public speaking, for example – but virtual scenarios for trauma emerged later with the introduction of “Virtual Iraq” from Dr. Skip Rizzo at the University of Southern California. In 2009 – when the U.S. Army asked me if I would take my earlier work with Vietnam veterans and adapt it to treat veterans returning from Iraq and Afghanistan – I saw the perfect opportunity to incorporate VR into the exposure therapy component of our treatment program at UCF RESTORES.
From 2010 to 2016, we were working strictly with veterans and active-duty personnel. Then, the Pulse Nightclub tragedy occurred, and first responders began turning to us for treatment – and we were quick to open our doors. We started with treatment for the first responders who were at the club that night but, as the success of our treatment became known, more first responders began to request treatment for different types of traumatic events. It became evident that we needed a VR system that would allow us to design scenarios for the myriad of traumatic events that occur in this country – combat, sexual assault, mass casualty, natural disasters, and other traumas experienced routinely by first responders. So, that’s what we built.
Our proprietary treatment tool does not limit us to a number of predetermined scenarios; rather, we can develop scenarios as we need. We have also integrated sensors into the system so that we can monitor a patient’s physiological distress, which allows for even more effective and powerful treatment.
A pilot trial of the system with 18 first responders revealed that we were able to use the system effectively and that all patients experienced significant improvement after just two weeks of treatment – rather than our standard three. None of the first responders met the diagnostic criteria for PTSD after this two-week program. We are excited to continue perfecting this system, and our ultimate intent is for trained clinicians across the country – and eventually, the globe – to be able to use the system with very minimal financial investment.
The article references the potential to see these types of VR systems “in people’s homes.” In your view – how, exactly, should the future of VR in psychological treatment take shape?
Since COVID-19, telehealth has become a standard practice for the provision of psychological treatment. This mode of therapy is here to stay, as many individuals are not able to go to a clinic for treatment, either due to distance, family responsibilities, or a similar factor. A number of randomized controlled clinical trials (e.g., Acierno et al. 2017) have demonstrated that exposure therapy can be delivered via telehealth. So, the challenge now is to determine whether we can add the virtual reality aspect to telehealth delivery.
Although I do not believe that trauma treatment should ever be placed solely in the hands of the person seeking treatment for PTSD, the changes in technology – increased quality and lower hardware costs, for example – allow us to consider how we can expand the use of VR to treat more people successfully and efficiently. For example, it may be possible to send a headset to a patient, who would then connect with the therapist via telehealth. Just as in any other type of therapy, the therapist would be in charge of the session, but the patient would no longer have to come to the clinic in order to use the VR system.
In the article, the Department of Veterans Affairs Director of Clinical Technology Innovation noted that, “It is a lot easier to multiply headsets than mental health providers.” We know it can be challenging to find a clinician trained in virtual reality exposure therapy – or even, for our first responders, in cultural competency. But we also know the importance of having a trained clinician involved when it comes to psychological treatment.
How is UCF RESTORES working to bridge this gap / support the growth of trained and culturally aware mental health clinicians? What can others in the field do to support you in this charge?
We are addressing this gap in several ways. First, we have developed – and have online – a training course for clinicians who are interested in learning about our highly effective trauma treatment, known as Trauma Management Therapy (TMT). TMT brings together group therapy – where we address skills such as sleep hygiene, anger management, behavioral activation for depression, and social reintegration – and individual exposure therapy. The course is highly engaging (not death by PowerPoint!) and includes videos of our clinicians conducting therapy, as well as exercises that reinforce the didactic material. At the end of this course, clinicians can become certified in TMT.
Additionally, we are now engaged in training clinicians in how to work effectively with first responders – what we call cultural competency training. The fire service and law enforcement each have completely unique cultures, and first responder lifestyle is not always apparent or easy for civilians to understand. For clinicians to be successful in the treatment of first responders, it’s vitally important that they be trained in the details of first responder lifestyle and culture.
Furthermore, first responders see life’s most horrific moments … and often they see them repeatedly. Culturally, we are finally turning the corner on first responder stigma; many first responders are asking for help rather than simply insisting, “I’m fine.” Yet so many first responders have told us that their previous therapist “fired them” because the therapist became overwhelmed by the horrific events the first responder had witnessed. We decided to take on the issue of cultural competency because first responders deserve therapists who understand their culture and who will provide evidence-based treatments.
This year, we are conducting a series of workshops across Florida to provide this training, and – in the case of the fire service – have partnered with the Florida Firefighters Safety and Health Collaborative’s highly successful Clinician Awareness Program. Our long-term plan is to make these in-person workshops available online and to offer them to clinicians across the United States.
Acierno et al. 2017, “A non-inferiority trial of Prolonged Exposure for posttraumatic stress disorder: In person versus home-based telehealth – ScienceDirect”