Hunter Hoffman
Your first approach to VR was in 1993, at a time when this field was much less developed. Nevertheless, you decided to focus your research on it. What made you make this decision?
I was studying about a very interesting topic: how people separate fact from fantasy, how do you remember if something really happened or if you only imagine it to have happened. One of the reasons I was interested in using VR was to do memory experiments. During the study phase of the experiment, we showed people 24 objects, 12 real -seen with the VR helmet lifted up- and 12 virtual objects seen in the VR helmet. A week later, they came back and we gave them 36 test questions. On the test, for each object, they had to respond if they were real, virtual or new. If they saw the object directly, the correct response was "real". If they saw the object in the VR helmet, the correct response was "virtual", and if they did not see the object in our experiment one week before, the correct response was "new". We also played some tricks on them: for instance, during the study phase, while they were watching a virtual object, we gave them a real one to be touched. This fact made them feel confused on the test: "I think this object was real because I remember myself touching it", they said a week later. They mixed real and virtual. One of the things I noticed is the more that people feel in VR, the more isolated they are from the real world. If you really believe you are in a virtual world, you are not in the real world anymore. This idea proved valuable later when I began using virtual reality to help treat patients for phobias, and to help distract burn patients; in short, in medical applications of virtual reality.
And then, in 1995, you developed a new VR therapy for spider phobia. How did it work?
I got a phone call from a therapist who told me that he had a spider phobia patient and he wanted to treat her with VR ?actually, it was the patient's idea, because the therapist wanted to treat her with drugs. So, I designed the program SpiderWorld [a 3D VR program containing images of spiders]. We used it to treat the patient and it was an enormous success. After a few one-hour sessions, she was getting better and better. At the beginning of each session she felt very anxious, with a lot of emotion, but after about 10, 15 or 20 minutes she calmed down. It involved very repetitive work. During the last few days of her treatment, I realised I was able to use the mixed reality technique I had developed during my early research. For example, we mixed a virtual spider with the sensation of touching it. The patient had the illusion of physically touching the virtual spider. The patient realised she wasn't afraid of spiders anymore. After 10 one-hour treatment sessions, the patient was able to hold a live tarantula in her hand with only moderate fear. We would not usually ask a patient to do that, but we were filming a documentary: Scientific American Frontiers. The first research study using VR to treat spider phobia was conducted in collaboration with the research group at Jaume I University in Spain.
After this achievement, you devoted yourself to VR pain distraction aimed at patients with severe burns.
Yes, my friend John Everett introduced me to burn researcher Dave Patterson. Patterson and I co-originated the idea of using virtual reality to distract patients during painful procedures with burn patients. When we tested the new technique on his burn patients at the hospital, it worked immediately. Patients put on a virtual reality helmet -in order to show them VR images- and they forgot about their pain.
Your first burn patients were children, weren't they?
Actually, the VR game SnowWorld [launched in 2001] was specifically designed for children, but it also works well with adults. It's especially tragic when a child is burned. It's really terrible for a child to have to suffer so much pain. They are so innocent. This is the reason why I was extremely interested in helping children.
Did you observe different responses depending on the age of patients?
We thought that children would be more likely to live in a fantasy world, so we considered it would be easier for them to get into SnowWorld. What we found is that the virtual reality distraction worked equally well for adults and children. My theory is that children are the more drawn into the VR world without trying. Adults are initially more likely to be skeptical, but once they realise that the therapy reduces their pain, they pay more voluntary attention. If you want to focus your attention, it's easier if you are an adult than if you are a child. You can concentrate for longer.
Besides the States, this program is being used nowadays in some European hospitals as far as I know.
Yes, it's being used in Groningen, in Netherlands. It was one of the first places to publish a paper on VR pain distraction. They are getting good results. In addition, it's being used in Canada too, and in at least six burn centers in the United States. There are two or three more hospitals trying to raise money to get a VR pain distraction system to reduce patients' pain, and there appears to be growing interest in VR analgesia.
What about Spain?
Spain has some of the world's leading researchers in the area of VR use for helping mental problems, such as anxiety disorders, phobias and depression. I have been collaborating with Spanish researchers. They are also exploring the use of VR for pain control but they aren't using SnowWorld. They have a different angle: they are treating a different patient population, not specifically burn patients. They are exploring the use of VR to supplement more traditional therapy approaches for chronic pain. Spain is one of the leading countries for VR therapy.
JoAnn Difede and you are the authors of the first controlled study on using VR in therapies for Post-Traumatic Stress Disorder (PTSD), published in 2007. In this area, therapists use virtual reality during therapy sessions to help witnesses of terrorist attacks, like the ones of September 11. Moreover, you are working with American soldiers who took part in the wars in Iraq and Afghanistan -using the program IraqWorld-, and who now have psychological problems. What are these patients like?
Typically, about 15% of the people who have gone through a traumatic event like the terrorist attacks on the World Trade Center subsequently develop long-term psychological problems. About 85% of civilians who experience a traumatic event such as the September 11, 2001 attacks initially show PTSD symptoms, but these symptoms gradually go away even without treatment. About 15% of people who witness or experience a traumatic event continue to have psychological problems long after the event has passed. This 15% typically do not get better without treatment. Their symptoms remain, and if they don't get treatment, in 5, 10 or 20 years they will still have mental problems. People with PTSD avoid their own memory of traumatic events. They don't want to think about it; it's too emotionally painful. They avoid people and situations that remind them of the traumatic event they find too painful to think about. That's the reason why their circle of friends gets smaller and smaller. For September 11 patients, they stop going to tall buildings or taking planes... Gradually, they become more and more trapped because of their psychological issues. Perhaps because of their avoidance, the brain can't heal itself. People who get better are the ones who talk about it. Even though this is painful, they process their emotions, and then after a few weeks they are more comfortable thinking about it. So, the therapy involves talking about it with their therapist. Patients see the World Trade Center in the virtual reality goggles during therapy, to help them remember their own traumatic experience on September 11.
Really? This is amazing...
Many patients with PTSD have what is known as survivor guilt. They feel bad because of those people that died during the attacks and they are alive, for example, maybe because they were late for work on September 11. Then, the therapist tries to explain to them that being alive is not their fault and there's nothing to feel guilty about it. It makes them feel better. They need to have their memory activated during therapy to make it healthier. One of the reasons why VR is so effective is because it really helps people to recall the memories they have been trying to avoid. It makes it easier for the therapist to treat the patient.
Could you tell me about any other profiles of PTSD patients who go into therapy?
For example, we can talk about witnesses of terrorist attacks in Jerusalem. In the treatment, we show them a small virtual explosion with no sound effects, and then we start adding more elements. We created the program BusWorld to help them. Initially, it is unpleasant for them to recall the painful memories of what happened, but after doing it day after day they become more comfortable thinking about it, and their PTSD symptoms become weaker with each therapy session.
What is the rate of success for these VR treatments?
It's a little early to say. In the study I did with JoAnn Difede we had 10 patients who had been treated with VR and about 10 more patients who hadn't received any treatment. The ones with no treatment didn't get better, but 9 of 10 patients who had received a VR treatment showed some improvement. One of biggest tragedies of PTSD is that the vast majority of patients never receive treatment. For example, only the 7% that suffers it because of sexual abuse gets some therapy during the first year after the attack. One of the reasons is that they want to avoid thinking about it. At least two papers show that people with anxiety disorders are much more interested in coming into therapy if it involves VR. And also it involves less stigma. Part of the reason people don't come into treatment is because they feel that their friends are going to think they are crazy. Instead of this, if you say: "I'm going to get VR", this is more acceptable. I think VR works as well or better than conventional treatment, and it has the advantage that more people will see treatment in this way.
How successful is VR therapy for treating combat-related PTSD?
The success rate of treating combat-related PTSD is very high for those who complete therapy, but nearly half of soldiers with PTSD never receive any treatment. And even patients who get VR therapy sometimes drop out prematurely. Dr Difede and others are exploring ways to reduce the number of therapy sessions that are needed for patients to get better -for example, using therapy enhancing medications in combination with virtual reality therapy. This could prove extremely valuable. For instance, many patients need 10 or 20 therapy sessions, usually one therapy session a week for three months. If the number of therapy sessions could be reduced, more patients would probably complete therapy. VR is not a magic bullet, but it is a valuable tool to help therapists treat patients more effectively. A successful therapy means fewer nightmares, fewer flashbacks, being more sociable... It's quite challenging to treat these patients. They deserve the best treatment after sacrificing themselves for their country. We have to help them recover before their marriages break down and before they start abusing alcohol and other substances.
From your view, which further advantages could be provided by VR analgesia to improve wellness in other patients, besides PTSD and burn patients?
VR is also used on patients with a clinical diagnosis of claustrophobia. For instance, in the case of a patient who is unable to tolerate a brain scan. People who are afraid of small places become very anxious when in a brain scanner, which is a small tube. SnowWorld could be useful to distract them. You are not actually curing them, just helping them to get through the brain scan. We found that it worked extremely well. With no VR, one patient was unable to tolerate a brain scan for more than 10 minutes. With VR, she was only thinking about SnowWorld. She was distracted from having unhealthy thoughts. This study was also a collaboration between me and Azucena García Palacios and Cristina Botella from Jaume I University.
Finally, what do you think about the contribution of virtual universities like the UOC in promoting research on ICT?
I'm very impressed to see how advanced Spain is in this field. I do think that more and more things that required physical presence can now be achieved thanks to Internet. It's an unavoidable trend. Thanks to this, access to knowledge can be more efficient with the use of technologies, and I consider that a virtual university can provide it. Actually, one of the projects in which I'm involved has to do with taking VR to public schools and kindergarteners. Attention and memory are closely related. So if we want to improve memory, we need people to devote their attention to it.
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