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The Ultimate Skinner Box: Clinical Virtual Reality 1990-2016

IEEE Standards Association, @ieeesa

By: Skip Rizzo, Ph.D., Director of the Medical Virtual Reality Lab, University of Southern California Institute for Creative Technologies, Los Angeles, CA.

The last decade has given rise to a dramatic increase in the global adoption of innovative digital technologies. This can be seen in the rapid acceptance and growing demand for mobile devices, high speed network access, smart televisions, social media, hyper-realistic digital games, behavioral sensing devices, and now the 2nd coming of Virtual Reality! Such consumer driven technologies that were considered to be visionary just 10 years ago have now become common and increasingly essential fixtures in the current digital landscape.

At the same time, the power of these technologies to both automate processes and create engaging user experiences has not gone unnoticed by behavioral healthcare researchers and providers. In fact, it was during the "computer revolution" in the 1990's that promising technologically-driven innovations in behavioral healthcare had begun to be considered and prototyped. Primordial efforts from this period can be seen in R&D that aimed to use computers to enhance productivity in patient documentation and record-keeping, to deliver "drill and practice" cognitive rehabilitation, to improve access to care via internet-based teletherapy, and in the use of virtual reality simulations to deliver exposure therapy for phobias like fear of heights, flying, and public speaking.

The clinical use of VR was especially compelling back in the early-to-mid 90's as clinical scientists, dissatisfied with the limited old school methods of medical practice, psychotherapy, and rehabilitation began to get excited by the potential power of the computer revolution for reshaping and improving clinical care and research. At this time, VR was seen as not simply a case of automating the paradigms of the past with computing, but as way to create highly realistic, interactive, and systematically controllable stimulus environments that users could be immersed in and interact with to support clinical assessment and intervention.

In this regard, VR was seen as an advanced form of human–computer interaction that allows the user to ''interact'' with computers and digital content in a more natural or sophisticated fashion relative to what is afforded by standard mouse and keyboard input devices. And with immersive VR, produced by the integration of computers, head mounted displays (HMDs), body tracking sensors, specialized interface devices and real-time graphics, patients could be immersed in a computer generated simulated world that changed in a natural or intuitive way with head and body motion to provide novel opportunities for clinical purposes.

From this, VR was seen to offer the potential to create systematic human testing, training and treatment environments that allowed for the precise control of complex, immersive, dynamic 3D stimulus presentations, within which sophisticated interaction, behavioral tracking and performance recording was possible. Much like an aircraft simulator serves to test and train piloting ability under a variety of controlled conditions, VR could be used to create relevant simulated environments where assessment and treatment of cognitive, emotional and motor problems can take place under a range of stimulus conditions that are not easily deliverable and controllable in the real world.

When combining these assets within the context of functionally relevant, ecologically enhanced virtual environments, a fundamental advancement was envisioned to emerge in how human assessment and intervention could be addressed in many clinical and research disciplines. This "Ultimate Skinner Box" was what human experimental researchers and clinicians had always dreamed of, whether they knew it or not! And this was the "vision" that drove the enthusiasm for "Clinical VR" in the 1990's!

But it wasn't an easy road getting to a place where we could manifest that vision! For example, when discussion of the potential use of VR applications for human research and clinical intervention first emerged, the technology needed to deliver on this vision was not in place. Consequently, during these early years VR suffered from a somewhat imbalanced "expectation-to-delivery" ratio, as most who explored VR systems during that time will attest.

Computers were too slow, computer graphics were primitive, 3D user interface devices were awkward and required more effort than users were willing to expend to learn how to operate effectively with them, and head mounted displays (HMDs) were costly, bulky, and had limited tracking speed, resolution and field of view. Thus, in 1995, VR experienced its own nuclear winter as the public became disenchanted with the quality of a typical VR experience and the technology languished for many years in what the Gartner Group has termed "the trough of disillusionment".

In spite of this, the vision of Clinical VR was sound and VR "enthusiasts" continued to plug away at the R&D needed to advance the technology and document its added clinical value. And, over the last 20 years, the technology for creating VR systems gradually caught up with the vision of creating compelling, usable, and effective Clinical VR applications. This period saw dramatic advances in the underlying VR-enabling technologies (e.g., computational speed, 3D graphics rendering, audio/visual/haptic displays, user interfaces/tracking, voice recognition, intelligent agents, and authoring software, etc.) that now supports the creation of low-cost, yet sophisticated, immersive VR systems that are capable of running on commodity level computing devices. In part driven by the digital gaming and entertainment sectors, and a near insatiable global demand for mobile and interactive networked consumer products, such advances in technological "prowess" and accessibility have provided the hardware and software platforms needed to produce more adaptable and high-fidelity VR scenarios for the conduct of human research and clinical assessment/intervention.

Thus, evolving behavioral health applications can now usefully leverage the interactive and immersive assets that VR affords as the technology continues to get faster, better and cheaper moving forward deep into the second decade of the 21st Century! Moreover, a significant scientific literature evolved, almost under the radar, since the 1990's indicating positive outcomes across a range of clinical applications that leveraged the assets provided by VR. Such scientific support for the clinical efficacy and safe delivery of VR-delivered care served to also inspire the current view that technologic innovation may also help reduce the escalating healthcare costs that have become one of the hallmarks of post-industrial western society.

A short list of areas where Clinical VR has been usefully applied includes:

  • Fear reduction in those with specific phobias
  • Treatment for PTSD, depression, and paranoid delusions
  • Discomfort reduction in cancer patients undergoing chemotherapy
  • Acute pain reduction during wound care and physical therapy with burn patients and in other painful procedures
  • Body image disturbances in patients with eating disorders
  • Navigation and spatial training in children and adults with motor impairments
  • Functional skill training and motor rehabilitation in patients with central nervous system dysfunction (e.g., stroke, TBI, SCI, cerebral palsy, multiple sclerosis, etc.)
  • Assessment and rehabilitation of attention, memory, spatial skills and other cognitive functions in both clinical and unimpaired populations

To do this, Clinical VR scientists have constructed virtual airplanes, skyscrapers, spiders, battlefields, social settings, beaches, fantasy worlds, and the mundane (but highly relevant) functional environments of the schoolroom, office, home, street and supermarket. In essence, VR environments can now be created that mimic real or imagined worlds and apply them clinically to immerse patients in simulations that support the aims and mechanics of a specific assessment or therapeutic approach. As a result, there is a growing consensus that VR has now emerged as a promising tool in many domains of clinical care and research.

As we look to the future, we see Clinical VR as one of the larger domains of general VR usage. In the recent Goldman Sachs market analysis looking at the future of VR into 2025, we of course see that Gaming and Entertainment garners the largest market share. While that is to be expected with the public's chronic demand for new and better ways to consume media, the little noticed item in that market analysis is that "healthcare" comes in second for the VR market share. This is not a surprise to folks who have worked in this area over the years, especially as we see healthcare costs becoming one of the largest line items in the US Govt. budget, after Defense. Entrepreneurs have also taken note of this as the number of new clinically-oriented VR start-ups in the last two years outnumbers the total for the previous 20 years! And the exciting and scientifically-informed innovation in Clinical VR we have seen thus far is just prelude!

In addition to the refinement and expansion of existing Clinical VR systems, the next generation of these applications will leverage the powerful advances in Virtual Human (VH) technologies to support credible interactions between patients and VH agents. But we will save the discussion of this domain of Clinical VR for a future installment of this blog!

About the Author
Albert "Skip" Rizzo is the Director for Medical Virtual Reality at the University of Southern California Institute for Creative Technologies and has Research Professor appointments with the USC Dept. of Psychiatry and Behavioral Sciences, and at the USC Davis School of Gerontology. Dr. Rizzo conducts research on the design, development and evaluation of Virtual Reality (VR) systems targeting the areas of clinical assessment, treatment and rehabilitation. This work spans the domains of psychological, cognitive and motor functioning in both healthy and clinical populations. Skip will provide insight on this topic at the annual SXSW Conference and Festival, 10-19 March, 2017. The session, AR/VR: The Promise and Danger Behind the Hype, is included in the IEEE Tech for Humanity Series at SXSW. For more information please see

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