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From “The Ultimate Display” to “The Ultimate Skinner Box”

Virtual Reality and the Future of Psychotherapy

Marisa Brandt

Albert “Skip” Rizzo: Whereas in the mid-90's VR was generally seen as “a hammer looking for a nail,” it soon became apparent to some scientists in both the engineering and clinical communities that VR could bring something to clinical care that wasn't possible before its advent. [. . .] The capacity of VR technology to create controllable, multisensory, interactive 3D stimulus environments, within which human behavior could be motivated and measured, offered clinical assessment and treatment options that were not possible using traditional methods.

(Rizzo et al., 2010, p. 117)

Psychology is the physics of virtual reality.

(William Bricken, quoted in Barlow et al., 1990)

Introduction: Cybertherapeutic Reason

The scene in the virtual desert takes up my entire field of view. If I look up, I see my gunner. Behind him peeks blue sky. Looking down, I see what I recognize as “my” masculine arm (though it is not attached to me) clothed in a sleeve of digital camouflage, gripping the steering wheel of a Humvee. To my right, my passenger, a racially ambiguous soldier character, is nodding and shifting weight just enough to give him some ersatz liveliness. Before me lies the flat gray road, mostly barren, some blocky architectural structures in the distance, and straight ahead another Humvee in the convoy. As I press the thumb controller button, we coast along the virtual desert. A sniper fires from an overpass. Cracks appear on the windshield and my passenger, digital blood on his fatigues, doubles in pain. I press onward, past stopped cars. “Are you ready?” asks the researcher. I nod. Click. The Humvee ahead of me explodes, and the base-shaker under my chair and the controller in my hand shake while black smoke fills the goggle screens.

For now, this kind of scene is recognizable from playing a videogame or even participating in a military training program. But instead, imagine – as I was asked to do, during the demo at a Southern California-based interactive media laboratory – that this could be part of a scene of psychotherapy. Therapy using virtual reality (VR) is one of the most well-publicized innovations in treatment for post-traumatic stress disorder (PTSD) among service members returning from the wars in Iraq and Afghanistan. I came to the media laboratory, as many journalists, military funders, interested clinicians, and technology innovators do, to experience this technology for myself and to learn why its advocates believed that experiencing a virtual version of Iraq could be therapeutic for men and women traumatized by combat. Why were so many so hopeful about the therapeutic possibilities of VR?

Advocates believe that the benefits of VR to therapy are twofold. First, they give cultural reasons, arguing that VR could encourage people to try therapy who otherwise might not, especially the newest population of young, male service members who might view talk therapy with stigma, but who in all likelihood have some experience playing videogames. Some VR therapy innovators have argued that patients who grew up in the “digital generation” are used to using digital media in order to communicate with friends and family, and so will be more comfortable interacting with virtual environments than merely talking with a therapist.¹ Advocates also give technical and professional reasons, arguing that conducting therapy in virtual environments will enable therapists to provide controlled therapeutic experiences that will improve the efficacy of care based on exposure therapy. Exposure therapy is an empirically supported treatment for PTSD in which the patient revisits traumatic experiences in order to move past them. Given that problems including homelessness, alcoholism, unemployment, and domestic abuse are all associated with PTSD, providing efficacious care is seen not only as an important ethical issue, but also as a problem of governance and social integration for a new population of veterans from Afghanistan and Iraq, returning to the United States with signs of PTSD.

Like innovations in training technology, VR therapy relies on a view of non-technologically mediated, face-to-face communication as insufficient to the task of remaking selves. Training simulators, such as those used in aviation, medical education, and military training, utilize interactive graphic interfaces to help transform novices into experts by making training more engaging and concrete than traditional instruction. In the case of VR therapy, the hope is that interactive technology will provide experiences that will help transform mentally disordered people into healthy ones.

The integration of new media technologies into psychotherapeutic practice represents an important development in the techniques of self-making. Therapy is a key site of the practices of modern self-identity construction (see Giddens, 1991). Psychotherapy is founded on a faith in the capacity to know and transform individuals according to rational principles. From psychoanalysis to self-help books to psychopharmacology, the psy disciplines have been looking for increasingly effective, efficient, and rationalized technologies for improving selves, often centered on an image of perfect mental health as a balance between self-knowledge, feelings of efficacy, and overall contentment with one's position in the world (see, e.g., Healy, 1997; Rose, 1996; Szasz, 1984).

Cognitive-behavioral psychology, of which exposure therapy is a product, is a branch of psychotherapy that treats human beings as a part of systems: the mind itself is imagined as a set of structures that process the world. Originating in the 1960s, this model of subjectivity is cybernetic, that is, constituted through the exchange of information between subjects and their environment. Cybernetic models of subjectivity are particularly conducive to seeing the person in mechanistic terms, as an information processing system, and therefore capable of being reprogrammed. Similarly, N. Katherine Hayles (1999) has shown that the experience of “reality” in VR is based on cybernetic principles of subjectivity. As Hayles explains, in the cybernetic view of subjectivity, from the perspective of the human sensorium the world is information. The subject experiences the information as a world, whether embedded in a material reality or a virtual one. By the 1980s, researchers began to develop technologies to present the sensorium with “virtual worlds” that could become a viable new site for human evolution (Hayles, 1999, pp. 13–14; see also Hillis, 1999). Virtual reality suggested that we could create an environment we liked, leaving “real life” behind. Cognitive behaviorism suggested that if we could change our way of thinking about our place in our environment, we could change ourselves.

Thus, while the use of VR in therapy seems ironic on the surface, advocates believe that virtual environments can be used to improve how subjects interact with the actual world. I use the term “cybertherapeutic reason” to describe the underlying rationale behind VR therapy: the belief that well-designed human–computer interaction can help therapists to cure mental illness. ² I have adapted this concept from the anthropologist Andy Lakoff's term “pharmaceutical reason,” which he defines as “the underlying rationale of drug intervention in the new biomedical psychiatry: that targeted drug treatment will restore the subject to a normal condition of cognition, affect, or volition” (Lakoff, 2005, p. 7). Cybertherapeutic reason underlies the development of new media technologies as therapeutic tools. Whereas drug treatments use specially designed molecules in order to fix malfunctioning physiological systems in order to improve psychological health, cybertherapeutic treatments entail sessions of human–computer interaction designed to improve overall psychological health. In addition to VR therapy, cybertherapeutic reason can be seen in the use of health-promoting videogames, smartphone-based expert system applications, and avatar therapy in virtual worlds (see Anthony, Merz, & Goss, 2010, for more examples). The cybertherapy movement represents an era of renewed faith in the field of psychological intervention, made possible by the affordances – and affordability – of new media technology.

The most important affordance of VR technology is the capacity to immerse patients in virtual environments, and the design of these systems reflects assumptions about what a healthy individual should be able to experience without problem. Journalists writing on VR therapy often note that the virtual environments appear cartoonish and unrealistic, while repeating advocates' claim that, for those suffering from mental illness, the environment will trigger their problems and reveal them. In the logic of cybertherapeutic reason, the healthy and the unhealthy can be distinguished by how they experience the virtual space: the virtual environment is not a space apart from the user's reality, but rather becomes a tool for assessing his or her health in the actual world. But no virtual environment can fully represent the world. Thus, the efficacy of VR as a tool of psychotherapy can only be assessed by its capacity to elicit “unhealthy” responses. The design of cybertherapeutic systems, therefore, can be seen as materializations of normative assumptions about healthy subjectivity. My own sense of calm within the virtual Humvee only serves to indicate that I am not the proper target of that VR therapy system: from the perspective of the system, I am a healthy psychological subject.

VR therapy does not refer to a single practice. It has been proposed as a tool to augment a wide variety of therapeutic styles. What they all have in common, however, is a belief that the combination of immersive stimuli and interaction with virtual environments can improve the effects of psychotherapy. I focus on two key points of comparison across VR therapy systems: (1) the conception of “realism” at play in the system design (that is, what kind of scenario the virtual environment represents and how it represents it); and (2) how the control-interfaces distribute agency over the objects and events in the virtual environment over the course of therapy. These two factors – realism and control – are key components in the role that VR plays in therapy.³

Though VR has spent the past two decades as the prototypical image of technological hype, this does not mean that media studies should abandon VR as an object of study.⁴ While some see the collapse of the commercial VR industry in the 1990s as evidence of the technology's failure, VR therapy advocates believe, on the contrary, that the technology has finally come of age. Whether or not the therapy advocates are right, the current interest in VR as a therapeutic technology is worthy of critical attention, especially for scholars interested in how subjectivities are being imagined and reconfigured in the emerging media environment. Examining therapeutic applications of VR requires a departure from conventional ways that media studies has approached its objects of analysis, especially a movement away from content and discourse analysis and toward careful attention to complex interactions between technological change and human subjectivity. In this chapter, I show how VR therapy was discovered as a potential tool for psychotherapy, which features of VR came to be defined as therapeutically significant, and how design variations reveal diverse interpretations of how VR can be used to transform the self. Finally, I speculate about some of the ways in which VR therapy might eventually transform psychotherapeutic practice.

A Hammer Finds its Nail: A Brief History of VR Therapy

Because of its ability to create “other” realities, virtual reality has always had interesting implications for human psychology.⁵ VR uses computer-generated sense-stimulating technologies that give operators the subjective experience of being in a three-dimensional space. In order to create this effect, immersive VR entails four components: a computer with a graphics engine, software that presents the user with a first-person perspective on a virtual space, a tracking device that monitors the user's body movements, and user interface technologies. The technology has its roots in human–computer interaction research. The graphical user interface was conceived as a technique that would make computers user-friendly by representing the seemingly incomprehensible volumes of information stored in computer databases as visual-spatial graphics that users could interact with in a “naturalistic” way (e.g., Engelbart, 1999; Licklider, 1999). But innovators realized that VR need not only represent data; it could represent any kind of environment the computer could render and generate any sensation that interfaces could simulate. Most historians trace the history of VR to 1965, when then-Harvard graduate student and later ARPA research scientist Ivan Sutherland proposed “the ultimate display,” “a room within which the computer can control the existence of matter” (Sutherland, 1965, p. 3). Three years later, Sutherland created the Sword of Damocles, the first binocular display with head-tracking (Sutherland, 1968). The heavy head-mounted display had to be secured to the ceiling in order to be worn (hence the name), but when it was, it created the illusion of three-dimensional geometric forms that could be viewed from multiple angles (Aukstankalnis, Blatner, & Roth, 1992).

Two decades passed before VR became practical enough to gain interest outside of research circles. In a 1986 interview in Scientific American, inventor and entrepreneur Jaron Lanier introduced the phrase “virtual reality”, only two years after Time magazine had heightened public awareness of the burgeoning digital age by declaring the personal computer the “Machine of the Year.” For some, VR meant that computers would allow us to create and explore worlds, expand our intelligence, and create culture-transcending “post-symbolic communication.” A flood of VR hype swept over US culture during the late 1980s and early 1990s, as technologists and journalists promised a future in which new interface technologies would revolutionize education, training, scientific research, art, and entertainment (e.g., Aukstankalnis et al., 1992; Heim, 1998; Lauria, 2001; Rheingold, 1991). Some media studies scholars viewed the virtual world as a site for struggle and resistance (e.g., Brook & Boal, 1995; Hillis, 1999; Markley, 1996), while a slate of science fiction films reflected cultural anxieties over the possibility of people getting lost in it, completely detached from reality and high on the power of virtual existence. In the film Lawnmower Man (Everett & Leonard, 1992), for example, a doctor uses VR to transform a simple-minded lawnmower driver named Jobe into a power-hungry virtual god with little connection to his former humanity. Along similar lines, a now-infamous Wall Street Journal article referred to VR as “electronic LSD” because of its capacity to create private, potentially mind-altering experiences (Zachary, 1990).

In retrospect, VR had very little impact on mental health in the early 1990s. The technology was far too expensive for most people to access, and it was only good at rendering simple architectural spaces and geometrical objects. But researchers found that users treated those virtual, if cartoonish, environments as real. The combination of audiovisual immersion, first-person perspective, and the ability to interact with the virtual environment created a feeling of being inside a mediated space, called “presence” (see Biocca, 1997). Presence allowed operators of VR systems to have “real” experiences. Early commentators often described the outsiders' perspective on presence: watching people in VR goggles crawling around the floor or ducking in response to some object only they could see (e.g., Aukstankalnis et al., 1992; Rheingold, 1991).

The therapeutic potential of VR began to come to light in the early 1990s. On opposite sides of the country, researchers discovered that VR would not only be experienced as real, but it could produce very real anxiety. To some this came as a surprise: after all, even if it felt real, users knew that it was not actually real. At that time, relatively few people had tried VR, aside from researchers and some curious visitors to arcades and trade shows. These were the contexts in which researchers discovered the therapeutic potential of VR. In 1993, Dr. Ralph Lamson, a psychologist at Kaiser Permanente Medical Group in San Rafael, California, claimed to have discovered “virtual therapy” while trying a demo of VR at a technology exhibition in San Jose (Lamson, 1997). Lamson discovered that the simulated experience of being in a tall building triggered his fear of heights. Reminding himself that he was in a safe environment allowed him to confront his fear, and, he told an LA Times journalist, he cured his acrophobia by the time he left the exhibit hall (Stevens, 1995). Shortly thereafter he began a VR exposure therapy study, immersing acrophobic patients in 30-minute session of VR. In the virtual environment, they began in a café, then could walk out a door which led to a patio, then to a bridge. Lamson found that for most, the environment felt real enough to trigger their anxiety, as it had felt for him: “‘Some people don't want to go out the door at all,’ said Lamson. ‘When they do, they wobble, spread their arms for balance, shake, or cry,’ all while standing in the middle of his office” (Stevens, 1995). Monitoring heart rate and blood pressure and instructing them in self-calming techniques, Lamson encouraged his patients to continue. He reported great success with most patients.

Across the country, at Clark Atlanta University, a doctoral student in computer science named Max North and his colleagues discovered the therapeutic potential of VR through a serendipitous moment in 1992 (North, North, & Coble, 1996). North's team was working on a flight simulator project, in collaboration with the US Army Research Laboratory and Boeing (Wiederhold, 2007, p. 163). A team member began to experience anxiety while working, and admitted that she suffered from fear of flying. North's team decided to experiment in using VR to cure her aviophobia by conducting exposure therapy using the same technology.

As one of the first people to see the world through the lens of cybertherapeutic reason, North was eager to explore the extent to which it could be applied to other phobias and other anxiety disorders. His early efforts were instrumental in enlisting other experts in the field to come up with the proverbial “nail” for the VR hammer – that is, the types of mental maladies around which VR could be defined as a therapeutic technology. In late 1992, North approached well-known VR researcher Larry Hodges at his office at Georgia Tech and proposed using VR to treat fear of public speaking (Wiederhold, 2007, p. 82). Hodges rejected the idea because the available computers were not powerful enough to render people. Though he initially found the idea silly, his brother-in-law, an Army psychiatrist, convinced him otherwise. They discussed what the technology could do and, from there, independently came up with the idea of treating fear of heights (Wiederhold, 2007, p. 82). In 1995, they conducted the first clinical trial of VR therapy with the help of Dr. Barbara Rothbaum, a clinical psychologist with expertise in exposure therapy working at nearby Emory. By 1996, Hodges and Rothbaum started a company, Virtually Better, Inc., to develop VR applications for a range of anxiety disorders, starting with specific phobias that were easy to model with virtual architecture, such as driving, heights, dark rooms, and open spaces. As VR technology improved, researchers eventually became able to populate virtual environments with digital human avatars, such as the passenger in my Humvee. In turn, the use of virtual human agents allowed virtual healers to begin treating more socially complex phobias, such as public speaking and being in public spaces (North et al., 1996, Wiederhold, 2004). Therapists also began experimenting with mixed reality, for example, incorporating haptic technologies that allow arachnophobics to touch virtual spiders. September 11, 2001, also proved important for virtual reality therapy, producing an increasing interest in treatments for fear of flying, exacerbated by security restrictions that would prevent therapists from entering airports with clients, as well as the development of a virtual World Trade Center disaster exposure therapy study (Difede, Cukor, Patt, Giosan, & Hoffman, 2006).

The Ultimate Skinner Box?

Although the clinical value of VR has seemed to lay in its ability to simulate the real, the emphasis in the design of VR therapy systems is not recreating reality but, rather, creating the most therapeutic experiences within current technological limitations.⁶ Creating therapeutic environments entails conceiving of treatment in terms of changing how a patient responds to a given environment, but virtual environments can only ever be simplified models of the world. Some therapists refer to VR as the “ultimate Skinner box” because of its ability “to bring simulated elements from the outside world into the treatment setting and immerse patients in simulations that support the aims and mechanics of a specific therapeutic approach” (Rizzo et al., 2010, p. 116). The term “Skinner box” refers to the operant conditioning chamber, designed by US behaviorist B. F. Skinner. The chamber was a box or room that allowed the experimenter to control the physical stimuli presented to a subject, and pairing these with rewards and punishments in order to control behavior (see Rutherford, 2009). Therapists had been successful using exposure therapies to cure phobias for decades, directing patients to imagine or even confront fear-inducing objects and situations in order to overcome their fears. When adapting VR to the treatment of specific phobias, the issue of what to represent in the virtual environment is fairly straightforward. Virtual environments were designed to represent these feared objects and situations, and, as best possible, aimed to allow patients to interact with them as they might in real life: using a steering wheel controller to drive a virtual car, pressing the buttons in a virtual elevator, or approaching a virtual spider in a virtual kitchen.

As cybertherapists have begun to experiment with VR for the treatment of more complex disorders, the question of what to include in the virtual environment and how the patient should be allowed to interact with it has proven to be very open to interpretation. The tables of contents of the journal CyberPsychology, Behavior, and Social Networking (established in 1998) demonstrate that an ever-growing global community of researchers across theoretical perspectives is now experimenting with VR as a tool for conducting psychotherapy across the spectrum of mental health disorders, with very different ideas about the kind of reality it should be producing. Especially outside of the United States, researchers have experimented with more diverse interpretations of how VR can intervene in subjectivity, using it to augment many kinds of therapy that employ imagination and simulated action (see Vincelli, 1999). For example, in the early 1990s, researchers at the Ojika Lab at Gifu University in Japan developed a form of sandbox play therapy for treating and diagnosing autism in children by observing how they play with figurines in virtual environments (Hirose, Kijima, Shirakawa, & Nihei, 1997). In addition, several groups of Korean researchers have experimented with using VR for role-play therapy for schizophrenics (Ku et al., 2003). The emphasis here is on immersing patients in common situations so they can learn how to effectively manage their symptoms in everyday life. Since the goal of treatment in this case is self-education about interpersonal effects of behavior, the design of these VR systems can focus more on “social realism” than on physical realism (Glantz, Rizzo, & Graap, 2003).

European researchers have experimented with using VR in experiential⁷ and psychodynamic therapy.⁸ The Italian psychologist Giuseppe Riva (2011) has used VR to treat eating disorders. In the environments he designs, patients see multiple models of their bodies, distorted to different proportions, in order to challenge their body image. They are encouraged to navigate virtual environments using different virtual bodies, in order to get a more realistic sense of how their actual bodies fit into the world. Here, the virtual is a site for producing experiences that the patient can contrast with reality outside of the goggles. Another Italian, Gabriele Optale, has used VR as therapy for erectile dysfunction, immersing patients in a world designed to engage them through symbolism. Patients visiting Dr. Optale's clinic navigate a virtual forest with paths and obstacles they can overcome while a voice recording talks about childhood themes, drawn from psychoanalytic theories of sexual development. Optale believes that this unique therapy helps his patients to confront and conquer their impotence through symbolic experiences, without having to talk at length about their own personal sexual history (Optale, Marin, Pastore, Nasta, & Pianon, 2003).

This brief survey of international VR therapy demonstrates that despite a popular conception of VR as offering access to alien worlds, the emphasis of the design of VR therapy systems historically has been to create virtual environments that correspond to actual settings. The “realism” of VR therapy systems does not require that these settings precisely resemble specific situations or places in the patient's actual life, but rather that it can create an evocative sense of presence for as many patients who struggle with that problem as possible. In the economy of design in VR therapy systems, reality is schematized, stripped down to an operationalized model of the world; in it, each element, be it physical or social, reflects an assumption about how to elicit and promote the control of unhealthy behavior. Designers' belief that interacting with carefully schematized virtual environments can affect how a patient will interact with the actual world is the key component of cybertherapeutic reason. But variation among these systems reveals the diversity of opinions about how best to use existing VR technology to intervene in subjectivity.

VR for PTSD: A Comparative Approach

The use of VR in therapy for post-traumatic stress disorder offers important insights for understanding cybertherapeutic reason. Psychotherapy includes many approaches to intervening in traumatized subjectivity, only some of which are reflected in VR therapy for PTSD. In this section, I compare three VR therapy systems for PTSD treatment – two developed in the United States and one in the Netherlands. While each of the three systems uses a virtual environment to represent the scene of war, they vary in terms of the type of realism they employ and their form of user control. I emphasize these two elements for comparison: (1) the kind of “reality” the system is designed to produce and (2) how the control-interfaces distribute agency over the objects and events in the virtual environment during the course of therapy. These elements are an important basis for comparing different VR therapy systems because they reflect both differences in the way that designers think about the possibilities of using VR in exposure, and important variables available in the design of VR technology itself, “interactivity” and “vividness” being the two components of the medium that Jonathan Steuer argues determine users' sense of presence (Steuer, 1992). Comparing these systems shows competing paradigms within the logic of cybertherapeutic reason regarding how VR should act as a psychotherapeutic tool.

By far the fastest-growing use of VR therapy is for the treatment of combat-related PTSD. In 2004, a widely cited New England Journal of Medicine report estimated that 11.2–17% of service members would develop PTSD as a direct result of fighting in the wars in Iraq and Afghanistan (Hoge et al., 2004). Subsequent reports have made even higher estimates. Because combat-related PTSD is notoriously difficult to treat compared to other forms of PTSD, the disorder has become a major focus for innovation in treatment. Hodges and Rothbaum conducted the first trials for treating combat-PTSD among Vietnam veterans in the late 1990s (Hodges, Rothbaum, & Alarcon, 1999; Rothbaum, Hodges, & Alarcon, 1999) with promising results. However, VR therapy for combat-PTSD did not receive a lot of public attention until 2005, when the US Office of Naval Research began funding the technique. Now VR therapy is lauded as a promising new paradigm for treating the current generation of veterans. In her editor's introduction to the February 2010 special issue of CyberPsychology, Behavior, and Social Networking on PTSD, Brenda Wiederhold notes that two of the five top links retrieved by her Google search for “PTSD technology issues 2009” “addressed the value of virtual reality (VR) for PTSD” (Wiederhold, 2010, p. 1). The special issue itself is a testament to the practice: of the 13 studies published in the issue, 11 are studies of VR therapy for PTSD, each of which cites the efficacy of exposure therapy as a warrant for using VR.

On the surface, VR therapy for combat-PTSD can be seen as treating PTSD as a “war-phobia,” in that it is an acquired behavior, though it is more complex than a simple phobia because the fear itself is not irrational. Combat-PTSD is characterized by intrusive memories, nightmares, and hyper-arousal to stimuli associated with the traumas of war-fighting. Uncontrollable anger and emotional numbing are also common responses. Sufferers often try to self-regulate through avoiding reminders of their trauma, which may manifest in behaviors such as reclusion, alcoholism, and insomnia. In their Virtual Vietnam experiment, Hodges and Rothbaum created virtual environments resembling the jungles of Vietnam and a virtual Huey helicopter that veterans could experience in order to overcome avoidance and confront the anxiety-provoking stimuli. These scenarios were chosen because they represented common experiences among Vietnam War veterans (Hodges et al., 1999, p. 11). As in the early VR therapy treatments for phobias, the authors justified their project using the language of cognitive behaviorism: repeated exposure to feared stimuli (in this case the war zone) would evoke the patient's fear response, leading to habituation and extinction (Hodges et al., 1999, p. 7). However, the design of the more recent generation of systems suggests more complex ways of thinking about the therapeutic use of VR for combat-PTSD.

VR-Enhanced Prolonged Exposure

Virtual Iraq/Afghanistan was developed by clinical psychology researcher Albert “Skip” Rizzo and engineering researcher Jarrell Pair at the University of Southern California's Institute for Creative Technologies. The current version of the system runs on one computer. The clinician views two screens, one displaying the patient's perspective, and the other a “Wizard of Oz” control panel displaying buttons that correspond to various locations and stimuli that can be added to the virtual environment. The patient wears a head-mounted display, stands or sits on a base-shaking platform during therapy, and receives audio stimuli through headphones. An optional scent-panel is also available to deliver evocative smells like gasoline and body odor.

Rizzo and Pair designed their system as a tool for conducting prolonged exposure therapy. In prolonged exposure, the therapist guides patients to retell the story of their trauma, each time adding more detail, and becoming increasingly emotionally engaged. Emotional engagement is seen as critical to the effectiveness of the treatment. They believe that by reliving the event, through telling the trauma narrative in the context of a safe environment, patients will not only come to dissociate the traumatic event from the feelings that give rise to their symptoms (a behavioral process), but will also become empowered by having transformed flashbacks – uncontrolled fragments of memory – into a coherent narrative (a cognitive one) (see also Losh, 2006).

VR is believed to aid in both remembering the narrative and becoming emotionally engaged. Like Virtual Vietnam, the Virtual Iraq/Afghanistan system was designed to include common scenes of action during deployment based on clinician feedback about frequently reported traumatic experiences. The designers also sent prototypes to Iraq and Ft. Lewis to get feedback on the realism of the representation. In the original version released in 2005, the virtual environments consist of a Middle Eastern city and a Humvee, though new environments, including ones in Afghanistan and a Southwestern United States desert, are also being added. Though the technology enabled the designers to represent the most common scenarios of traumatic events, the design of these environments was limited by the capability of the available technology, which prevented the designers from making them as crowded, dirty, or able to be explored as thoroughly as they would have liked in order to make users' experiences more realistic.

Virtual Iraq/Afghanistan was designed with an emphasis on clinician control. The clinician chooses which environment to place patients in, as well as positioning them in various sites within that environment, such as making them the driver, passenger, or gunner of the Humvee. In the city scenario, they can teleport the patient from market to mosque to checkpoint or several other locations. With a push of a button, then can add the sounds of mosquitoes buzzing or a voice yelling, “Go home, cowboy.” They can add or remove people from the streets, and blow up a surprising array of objects, especially parked vehicles. When these explosions take place, they can vary the “level of trauma,” meaning how much damage the explosion does to people, from leaving people in the area a little dazed to having them lose body parts.

The patient can navigate the environment using either a standard videogame controller (for the Humvee module) or a thumb controller mounted on a weighted mock M-16 rifle (for the city environment). In current versions, patients can only navigate the virtual environment: they cannot shoot or otherwise effect change in the world. Even though firing a weapon is an important, and potentially among the most traumatic experiences of war, the designers were concerned about the value of surmounting the technical challenge of designing a realistic killing scenario that would not transform the simulation into a “cathartic revenge fantasy” rather than a therapeutic emotional processing session (Rizzo et al., 2010, p. 117). In a newer version, however, the therapist will be allowed to turn on the shooting function briefly.

Here, the clinician uses the machine in order to evoke emotions and memories from the patient. The patient, while immersed in the environment, is primarily active through storytelling rather than manipulating the interface. The virtual environment, controlled by the therapist, is designed to act upon the patient's psyche.

VR-Exposure with Arousal Control

This method was designed by Brenda K. Wiederhold and Dennis Wood of the Virtual Reality Medical Center (VRMC) in San Diego, California. There are many similarities between Virtual Iraq/Afghanistan and the system developed at VRMC. Like Virtual Iraq/Afghanistan, the VRMC clinician's interface includes a screen showing the patient's point of view and another showing the clinician's control panel. In both systems the therapist has a similar range of controls, and can teleport the patient around the virtual environment and add similar elements, such as shouting or helicopters flying overhead. The virtual environments originally included a Virtual Baghdad, a Humvee scenario (which they call PTSD Convoy), and a “PTSD Village” (Wood, Wiederhold, & Spira, 2010, p. 5), though like the team at ICT, they are developing additional scenarios. Compared to the Virtual Iraq/Afghanistan system, VRMC's patient interface engages fewer senses, entailing only VR goggles with built-in headphones.

While the technologies appear to share many similarities in their basic design, they differ in the degree of agency given the patient. The VRMC system uses a model of VR exposure developed by the organization's founder, Brenda Wiederhold, in order to treat diverse anxiety disorders. The technique is called Virtual-Reality Exposure with Arousal Control (VRE-AC). Whereas Virtual Iraq/Afghanistan uses the system primarily to evoke memories and emotions to help the patients tell their trauma narratives, the VRMC system emphasizes “skills-building.” Though patients do tell the therapist about traumas they experienced, the therapeutic mechanism is not telling and retelling the trauma narrative. Instead, the therapist uses the biographical details in order to choose specific scenarios that patients will “play” during the course of therapy.

In VRE-AC applications, patients interact with the simulation in a manner similar to a videogame. Unlike the Virtual Iraq/Afghanistan system, patients not only can navigate the virtual environment, they can also use the controller to shoot an M-16 rifle (Wood et al., 2007, p. 311). Patients are given tasks, such as holding off insurgent fire while medics try to evacuate a fallen soldier, or driving their convoy to a specific location. Patients must do these tasks repeatedly. Realism is achieved both through virtual representation of spaces and through conducting the kinds of activities patients would actually conduct in the spaces represented.

VRE-AC environments are designed not only to trigger memories but also to actually allow patients to reenact traumatic scenarios in the simulation itself. Patients relive the trauma not through words but through actions. The emphasis here is on self-control. Before the VR session begins, the therapist teaches the patient meditation techniques in order to promote emotional, cognitive, and physical relaxation. During therapy, the patient is outfitted with physiological monitoring devices that measure skin conductance, finger temperature, respiration rate, and heart rate during therapy, which the therapist monitors on a third computer (Wood et al., 2007, p. 311). When the monitor indicates signs of physiological distress, the therapist draws the patient's attention to how he or she is feeling and directs the patient to stay calm using the meditation techniques.

This method is seen as skills-building, emphasizing the patient's ability to gain self-control through control over the situation at hand. Referring to her VRE-AC application for motor vehicle accident PTSD, Wiederhold says, “People who are afraid of the freeway say, ‘Oh my God, this is dangerous.’ I get them to stop the thought and think instead, ‘Yes, I'm sweating, but I'm still in control’” (Wiederhold, 2004, p. 43). The emphasis is not on making sense of the traumatic event but, rather, on learning to control one's own mind and body when confronted with those kinds of situations. As such, one learns how to confront reminders of the event that are both external and internal, such as memories. This model of agency is very different than the one invoked in the Virtual Iraq/Afghanistan system, which assumes that the patient will be healed through storytelling and habituation. By skills-building, the VRE-AC system deals with an important issue: what happens when the patient confronts another trauma, such as being redeployed to Afghanistan or Iraq?

Multi-Modal Memory Restructuring

A third system, designed by a team of researchers working at diverse institutions in the Netherlands, provides a helpful foil for comparing the Virtual Iraq/Afghanistan and VRE-AC systems. Unlike the other systems in which the world is ready-made with all possible scenes and elements already built into the software, in Multi-Model Memory Restructuring (3MR) the patients actually build the virtual worlds. They are taught to use 3D editing software to reconstruct a specific day into a six-minute story. In addition to graphical elements built into the system, they can also use geographical maps as well as their own pictures, which are uploaded into the software. Also unlike the other systems, 3MR is based on the group-therapy exposure model, in which patients draw maps and other visual aids in order to facilitate talking about their experiences of war (van den Steen, Brinkman, Vermetten, & Neerincx, 2010, p. 208). The system uses a laptop computer and a projection screen rather than a head-mounted display in order to allow the group to work together.⁹ Using what they call a “situated cognitive engineering approach,” the Dutch team does not emphasize direct exposure but, rather, “time sequencing of the memory content,” that is, telling the narrative (van den Steen et al., 2010). The primary role of the therapist is to help the patients learn how to use the technology in order to help them tell stories.

Like Virtual Iraq/Afghanistan, the main purpose of the 3MR system is to enable the construction of a narrative in addition to exposure. The other systems are based on generic scenes and actions, achieving a kind of realism through reflecting the designers' understanding of the common experiences of war based on surveys of service members. In contrast, the 3MR system allows the group patients currently using the technology to achieve realism by working together and using their own photographs. The emphasis here is on recreating the collective memory by amalgamating individual memories and mementos associated with a particular day. Also unlike the other systems, 3MR encourages the patients to include positive memories related to the same deployment, which might otherwise be forgotten (van den Steen et al., 2010). Here, therapeutic exposure means not only confronting the traumatic event and reliving the fear associated with it in order to overcome it, but also exposing oneself to the emotional and experiential complexity of deployment.

Therapists using the other systems could also ask patients to consider positive feelings experienced during combat; however, those positive elements are not apparent in the design of either system. Though one might argue that patients can successfully conduct missions in VRE-AC, this assumes that patients would necessarily experience these successes as positive experiences. The scientific journal articles and conference presentations promoting these technologies never address the possibility of using them to relive positive memories associated with deployment as one way to reframe their traumatic experiences.

Comparing VR Therapies

A comparison of these three therapies for PTSD demonstrates that VR therapy entails diverse strategies for mediating interaction between patient, therapist, and machine. It is not a matter of simply immersing patients in a virtual environment and having them emerge healed, but rather of a system designed to control the patient's experience within a therapeutic paradigm. All psychotherapies entail a model of how thoughts, emotions, physical feelings, and behaviors influence one another. But not all psychotherapists agree on how to intervene in these relationships. In some interventions, such as cognitive processing therapy, changing thought patterns is seen as a route to calming bodily feelings of anxiety. In others, such as the flooding technique for treating phobias, triggering emotions and physical experiences of fear in the absence of actual harm is believed to eventually retrain the mind.

At issue in these different interventions are questions of agency and control: what needs to be controlled and who needs to have control over it? Therapeutic rationale informs the design of VR therapy systems including how the virtual environment represents experience and how the ability to interact with it is distributed between the patient and therapist as distinct “users” of these systems. Understanding how cybertherapeutic reason plays out in VR therapy systems entails analyzing not only what they represent, but also the distribution of agency between the patient, therapist, and machine.

In VR therapy, agency over the virtual world is usually distributed unequally between the therapist and the patient. Control variables include who may choose which virtual environment the patient enters and what objects are present in that world. The goal is to train patients to respond to and understand their environment in different ways. For example, in Virtual Iraq/Afghanistan, patients are effectively learning that their traumas were things that happened to them, and that their only recourse is to face and learn to speak about them until they become like any other memory. The system reinforces this interpretation by giving most of the control over what happens in the external world to the therapist. In the VRE-AC system, by contrast, patients are treated more as active agents who must calm themselves in order to complete tasks: the trauma is not in the event per se, but rather in how patients respond to it. In 3MR, the group of patients is seen as a collective who use the virtual environment in order to create a multi-authored text representing their shared experience. They, too, are active agents in constructing how they remember an experience and realize through diverse perspectives that they have options other than interpreting the event as a trauma.

In the VR therapy community, one of the most important contributions of VR is its capacity to create “real” experience. But as we have seen, what counts as realism varies greatly. It may entail objectivized realism based on physical characteristics of the environment, a procedural realism based on actions, or a personalized realism based on recreating specific events, or some combination of these. The goal of realism in VR therapy is to partially shift representations of the world from the patient's imagination or the world itself, into a technological system. It becomes an individual experience through interactive processes such as the imagination, game-like interaction, or actually uploading personal images.

Whereas in traditional therapy the therapist cannot know for certain what is going on in the patient's mind, in VR, the external, controllable simulation comes to stand in for internal mental life. While the virtual is often contrasted with the material or the actual, in virtual reality, the digital representation of the world can be seen as a materialization of the patient's imagination: the digital representations, though merely light and sounds, are far more material than the imagination when it comes to the interaction of clinician and patient. Because the therapist sees what the patient sees (Gorini & Riva, 2008), VR therapists believe this can foster a common experience, perhaps contributing to therapeutic rapport. The therapist can instead ask for the terms that the patient uses for the objects, people, or places represented in the virtual world (Wood et al., 2010).

Objectivizing the patient's experience through VR also frees the therapist from some of the work of stimulating the patient's imagination. Being able to do so is seen in mental healthcare communities as a product of a good therapeutic alliance: the patient will only be able to generate useful mental images when he or she is comfortable with the therapist in the clinic. The challenge of building therapeutic alliance can be exacerbated when the therapist comes from a very different demographic than the patient population and does not have shared experiences to draw upon to help build mental imagery. After all, in most situations it would be socially inappropriate to disengage with the present and act upon one's imagination, especially when talking about a scenario with which one's interlocutor is completely unfamiliar. In VR therapy, the presence of the technology not only legitimizes the patient's mental transportation to an alternate psychological space, but it also structures this experience within the parameters of what the therapist believes the patient should be imagining. The virtual environment is designed to already “know” what the patient needs to experience in therapy, whether it is reliving a combat scene in Iraq or just being on a tall building. However, as many scientific articles on VR therapy argue, even when there is good therapeutic alliance, some patients, it is believed, have poor visual imagination, do not like to communicate through speech, and avoid dealing with emotional difficulties. As such, VR can be a powerful tool for clinicians when the patient either cannot or does not want to do what clinicians believe would be therapeutically effective.

Objectivizing patient experience can also have implications for the politics of subjectivity. Though the VR hype of the 1980s and 1990s promised an unlimited world of virtual exploration, virtual environments are closed systems, wherein both the world and actions within it are constrained by software code. While the software does not arbitrate what counts as a psychological problem, its design does reify what does and does not count as a normal response to it. Though some aspects of the design may be limited by current technological capabilities – such as the capacity to render compelling human forms – design can serve to reify concepts of normalcy by deciding, a priori, what is and is not a “normal” response. For example, in the VRE-AC system, the design of the technology makes an implicit argument that the “healthy” response to being shot at or being ordered to shoot someone is to control oneself. As such, VR can be used to materialize conceptions of healthy subjectivity within the context of therapy, while at the same time reducing the capacity of patients to resist turning over their imagination or emotions to therapeutic control. The artifacts have politics: they materialize an ideal, in this case, an ideal model of healthy subjectivity and self-control.

Conclusion: The Future of Therapy?

By 1996, Max North and colleagues were declaring virtual reality therapy a new paradigm in clinical care. With slightly more modesty, Kalman Glantz and colleagues noted that “VR technology may create enough capabilities to profoundly influence the shape of therapy” (Glantz, Durlach, Barnett, & Aviles, 1997, p. 92). As we have seen, the capacity to generate controlled, disorder-specific immersive experiences, all within the safe and confidential setting of a clinician's office, is the key technological contribution of VR to therapy. After years of being considered hype, VR is now being seriously considered as a therapeutic tool because it combines a kind of realism and controlled interaction that allow for the production of therapeutic experiences, based on a way of thinking about human–technology relationships that I call cybertherapeutic reason.

While VR therapy innovators are careful to insist that the computer is simply one more tool at the disposition of the healing profession, nevertheless, tools transform practices. If widely adopted, it will be important to document how VR changes the field of psychotherapy. It is possible to imagine a not-too-distant future in which therapists are no longer trained to use speech communication in order to elicit mental imagery, instead shifting the burden of this therapeutic skill onto technological systems like VR. Clinical psychology researchers currently debate the importance of “clinician effects,” by which they mean the difficulty of measuring the therapeutic efficacy of a specific paradigm because of the varying skill level of individual clinicians. VR therapy introduces the possibility of “software effects,” in which variations in therapeutic efficacy are attributed to the design or version of the software itself, including the existence of “bugs” or interface usability issues. Widespread adoption of therapeutic technologies such as VR has the potential to shift at least some of the responsibility for therapeutic efficacy from therapist to the computer. On the flip side, an individual therapist's lack of therapeutic efficacy may come to be seen as an issue of technical competency, one that can be addressed not only by improving his or her face-to-face rapport with patients, but also by outfitting the therapist with the most cutting-edge technologies and the skills to use them.

We are just reaching a time in which the number of people who will have visited virtual environments as part of treatment in a clinic will surpass the number of those who have done so during a demo at a research site. While the vast majority of clinicians do not currently utilize VR in their regular practice, this may soon change. In a poll asking American Psychiatry Association members about which inventions they expected to see increase in influence in psychology in the next 10 years, VR was predicted as number 3 out of 38 (Norcross, Hedges, & Prochaska, 2002).

The field has, indeed, been growing. Virtual healers have formed a research community, convening at an annual conference, Cybertherapy, which has grown in attendance and length since it began in 1996, and establishing numerous journals including CyberPsychology, Behavior, and Social Networking (est. 1998), Annual Review of Cybertherapy and Telemedicine (2003), Cyberpsychology (2007), Journal of Cybertherapy and Rehabilitation (2008), and PsychNology (2008). These forums have allowed virtual therapists to create a knowledge base for further research and field development. At the same time, the cost of buying and designing VR technologies has been dropping rapidly in the past decade, making these techniques increasingly accessible.

In recent years, powerful institutions, including branches of the United States military and Department of Veterans Affairs, have begun to express interest in VR therapy because it promises better therapeutic efficacy for treating PTSD, especially among members of the digital generation who are believed to be both comfortable with and attracted to interactive media technology. Further research is needed to examine the uses of VR therapy by these agencies, including the specific design of the VR systems they adopt. Doing so will provide new insights into how disordered subjectivity is defined, and how therapeutic interventions are conceptualized, as part of cybertherapeutic regimes. It is critical to examine how these institutions are coming to view the role of VR technology in reshaping the ways people interact with the world, and in the case of treating PTSD, how those afflicted communicate about, process, and heal from the traumatic experiences that now inform their lives.

NOTES

1 I distinguish between a virtual environment, or virtual architecture, and virtual worlds. Using Boellstorff's (2008) definitions, virtual worlds are populated, persistent spaces, such as massively multi-player online games (MMOGs), that can be studied as fields of social action. “Virtual environment” refers to any interactive simulated space.

2 There is no set term for the practice. I primarily use the term “virtual reality therapy” (VR therapy), coined by Max North and colleagues (1996), though others believe this sounds as though the technology autonomously provides care. Ralph Lamson called it “virtual therapy” (e.g., Lamson, 1997), though this implies that it is not “actually” therapy. It has also been called “virtual reality-enhanced therapy.”

3 Though the issue of attraction to technology is also important, I will not be addressing this issue here as it concerns how VR creates new meanings for therapy, rather than what it does in cybertherapeutic practice.

4 The full title of techno-evangelist Howard Rheingold's book on VR nicely sums up cultural ambivalence about where the technology would lead society: Virtual Reality: The Revolutionary Technology of Computer-Generated Artificial Worlds – and How It Promises and Threatens to Transform Business and Society (1991). Members of the field were also conscious of this ambivalence: the first SIGGRAPH panel on VR in 1990 was titled Hip, Hype and Hope – The Three Faces of Virtual Worlds. Woolley (1992) and Chesher (1993) have documented the VR of hype of the 1980s and 1990s. See Laurel (1993) on the collapse of commercial VR.

5 In the 1980s, both computers and postmodernism were transforming how people see the world. VR seemed to confirm the postmodern theories of the fluidity of subjectivity; if subjectivity is shaped by symbolic orders, then perhaps there is no one true reality and all realities are, in fact, virtual. See Lyotard (1984) and critique by Woolley (1992).

6 Because of high development cost and the slow process of clinical testing, VR therapy software often looks outdated compared to contemporary videogames. Advocates have suggested, however, that this is not a limitation but actually a feature of VR therapy, because visual simplicity leaves room for the patient's imagination to project onto the virtual environment, thereby personalizing the experience (e.g., Hollander, 2006; North et al., 1996).

7 Experiential therapists believe that experiences can expose and challenge patients' unconscious assumptions about the world and themselves.

8 Psychodynamic therapy also helps to reveal the unconscious to the patient by revealing origins of assumptions and challenging their role as patients' unhealthy coping mechanisms.

9 As of this writing, the 1980s dream of networked, interactive immersive environments is still too technically complex and expensive to be a functional way to conduct group VR therapy.

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