Walter Greenleaf, Ph.D. is an early pioneer in the medical application of virtual environment technology, and is viewed as one of the founders of the field. His focus has been on the use of virtual reality and telemedicine technology to treat Post Traumatic Stress Disorder (PTSD), addictions, Autism, and other difficult problems in behavioral medicine.
He talks about the types of medical applications of VR that have been studied and verified by research, and what the potentials are for implementing these in medical applications for the first time. He also talks about the impact of isolation that happens within elderly and disabled populations, and the social implications of have a way to interact online beyond using the keyboard and mouse.
Reddit discussion here.
Theme music: “Fatality” by Tigoolio
Rough Transcript
[00:00:05.412] Kent Bye: The Voices of VR Podcast.
[00:00:11.988] Walter Greenleaf: My name is Walter Greenleaf. I'm not currently doing anything in VR, but I have had a long history of being active and I'll be jumping back in again. In the past, I've been active developing medical applications of virtual environments, using virtual environments to treat post-traumatic stress disorder, to treat anxiety disorders, also to help with kids learning impulse control, addicts learning what we call refusal skills, using virtual environments to help with stroke and neural rehab and cognitive behavioral therapy in general.
[00:00:41.621] Kent Bye: I see. And so what type of experiences are people having when they put on a virtual reality head-mounted display? What are they seeing to be able to deal with all these various issues?
[00:00:51.834] Walter Greenleaf: Well, I think the first thing I should mention is that we often don't use a HMD. It really depends on the problem that we're dealing with clinically. For a problem where the brain doesn't want to go there for the therapeutic process, such as dealing with cognitive trauma, with post-traumatic stress disorder, or an anxiety disorder, a phobia, for example, we do use an HMD because the more sensory engagement we can get, the more changes to the brain we can initiate. However, for some of the other things that we're working on, for example, using virtual environments to teach someone situational confidence, if they want to learn how to say no when they're in a bar and someone offers them a beer, they have a problem with alcohol, they have to practice saying no and resisting peer pressure. We find that for social situations, just using a flat screen, as long as it's immersive in the form of 3D interaction, maybe 3D sound, we can get good results with that. We don't have to go with the full HMD. But your question was more, what does the person see? It really depends on what we're doing. If we're treating someone who has had a stroke and they're trying to recover function, we may make a very realistic world. Their goal might be to accomplish a given task, relearning a motor task. We might make the world very simple. So maybe it's a version of a home and they're just trying to get around the home and do standard activities. We make it very easy. They make a gesture towards the door, the door opens. They make a rotating hand with their knob and the stove turns on. And then we staircase them back up, making it gradually more and more realistic, taking it from easy to realistic, and to help them get there. So in that case, what we might have is a very, you might say, boring, real-world environment. On the other hand, If we're trying to treat some other clinical problems, we may, for example, when we treat combat post-traumatic stress, it's like a war zone. We may take them back to something very similar to what they saw in the combat zone. In that case, we redeploy some gaming environments to do it.
[00:02:46.617] Kent Bye: And so, can you talk about how do you treat PTSD? Do you do slow, incremental stimuli in terms of triggering? I'm trying to figure out how do you just not go overboard and just re-trigger someone with PTSD?
[00:03:00.162] Walter Greenleaf: That's a really sophisticated question and a good question. You could re-traumatize a person. The principle is what we call, I guess the best way to describe it is we're trying to immerse the person and do a habituation of what's a learned fear response. So for example, if you were in a war zone and driving on a Humvee and there was a pile of trash on the side of the road and you had to be hyper-vigilant all the time because you know there were IEDs along the road, that pile of trash blows up, your friend dies, you lose an arm. Later, when you're back driving down Interstate 280 in Cupertino, and you see a pile of trash on the side of the road, you're gonna have a learned fear response, because you learned that that was a dangerous situation. So what we try and do with treating combat post-traumatic stress is to habituate that learned fear response. Make it something that, instead of having a limbic system reaction in the brain, we have more of a frontal cortex reaction to the same stimuli. And to do that, we have to get the person to think about it, but maybe in a relaxed way. So we teach them relaxation skills and a clinician gradually takes them back to the traumatic event and has them process it and learn, you know, think it through. If done incorrectly, you can re-traumatize the person, you imagine. You can re-expose them to what they're afraid of and just reinforce the fear. So it has to be done by someone in a context that someone knows what they're doing.
[00:04:22.245] Kent Bye: And is that the same as using exposure therapy for PTSD?
[00:04:25.787] Walter Greenleaf: You're exactly right. The term is exposure therapy. And we use the same principle for treating fear of heights or fear of flying, etc. We gradually expose the person and habituate the fear response.
[00:04:36.192] Kent Bye: And so do you find that people, if they feel like it's too much, they just rip off the HMD or kind of just eject themselves from the virtual environment in some way?
[00:04:43.521] Walter Greenleaf: You know, I have to admit, I don't know. I've been developing the technology, I've been helping to sell the technology and do the research studies on the technology, but I'm not a clinician, so I've never actually sat with a patient, so I don't know. I see.
[00:04:56.572] Kent Bye: And so you mentioned that you're interested in getting back into virtual reality. Is there something with the consumer virtual reality with the Oculus Rift and this whole consumer VR movement that is pulling you back in?
[00:05:07.816] Walter Greenleaf: You know, I've gone through maybe five hype cycles now where everybody got very excited, there were a lot of bad movies made, and then it sort of died down because people were disappointed. I'm optimistic this time with, you know, the infrastructure is there with broadband. The cost of the computers to generate the virtual environments is affordable. And I think the public perception is, you know, we've all been playing games which are really often 3D multi-person virtual environments. We've been doing that for years. So I think now migrating the technology to the clinical world is going to be a lot easier. So I'm an optimist. I think this hype cycle will actually persist. The other thing I think is that we won't really be calling it virtual reality. I think this will all fade into the background. It will just be how we interact with the world, how we interact with 3D objects. I'm pretty sure that the automobile designers who use virtual reality to model their cars before they're ever built don't call it virtual reality. They probably just view it as their work environment that they design automobiles in. So I think that this cycle will burst through, become a common part of how humans are interacting with information.
[00:06:11.696] Kent Bye: And have you looked at any other specific disorders like anxiety disorder or any other type of ways to do medical treatments with virtual reality?
[00:06:20.179] Walter Greenleaf: Sure. Well, we've talked about stroke rehabilitation. We've talked about post-traumatic stress. Anxiety disorder is generally the same principle for that. And we talked about addictions, how we can use a virtual environment to help someone learn situational confidence. I guess the other area would be helping kids with autism and Asperger learn social skills. We can slow down the speed of the world, reduce the complexity of the world, give them a forum to learn to recognize social clues that otherwise might be hard for them to get. I can exaggerate your facial expressions. I can exaggerate your body language. So the communication that you and I take very naturally, because we sort of have the firmware to catch all that, we can exaggerate that so people who are trying to learn those social clues can do so in a stepwise manner.
[00:07:03.218] Kent Bye: And so are you at the point of kind of creating a hypothesis and then going out and doing research studies and building actual environments? Or what stage of the development do you fit in?
[00:07:12.943] Walter Greenleaf: I'd say that the field in general is actually pretty far along that we've already validated a lot of the approaches. So it's now a matter, I think, of applying the emerging technology with its lower price points and then working with the clinical community. The clinical community is justifiably slow to adopt new things. So we have to show the business value and the clinical value to get them to adopt it. So that's where the field is of medical applications virtual reality. It's transitioning from being a lab curiosity to starting to become something that's more out there. In terms of my own personal involvement, I guess I'm sort of at a pause point where I'm trying to decide where to jump back in. I'm working with some groups that are trying to take some of the e-health and mobile health technology and pair it up with pharmaceutical preparations to get a better combinational approach. And I'm also looking at joining a group that's doing some virtual reality upper extremity rehabilitation. So I'll probably decide in the next few weeks or so.
[00:08:06.289] Kent Bye: And have there been any actual applications that are VR applications for autism that are really slowing down the world? Since you said that it's sort of far along, I'm just curious of what's out there that people have done.
[00:08:16.767] Walter Greenleaf: You know, again, unfortunately, I think it's been mostly laboratory research showing the basic principles and validating the approach. There is a group up in Toronto that is doing a sort of a 2D approach to this thing, and I'm hoping to encourage some other groups to come up with a 3D approach. If I've missed anyone who's already out there doing it that I'm not aware of, please get in touch with me. But to my knowledge, it's mostly there isn't anyone who has it as a commercially available product yet.
[00:08:41.691] Kent Bye: I see. What are you the most excited about moving forward and seeing the potential of what can be done with consumer virtual reality?
[00:08:49.373] Walter Greenleaf: You know, I think the most powerful thing that excites me is the ability to build communities. I used to do a lot of work in the field of, I was head of the Mind Division at the Sanford Center on Longevity, which looked at aging. And I became very aware when I was in that role of how many of our seniors are having problems with isolation. We're getting better at extending life. We're all going to live a lot longer than our parents did and our grandparents did. But if we want to have a good quality of life, there's some things we have to pay attention to. And one of those things is social isolation. So I think one of the overlooked potentials for virtual environments is helping people with disabilities, people with impairments, people who are isolated for whatever reason, be part of a community in a very rich manner as opposed to just typing in a chat room. And I think that building communities locally, worldwide, I think that's going to be the more... Sure, virtual environments are going to be very profound for a whole variety of things, including the medical verticals that I just talked about. But I think the more profound thing is going to be our ability to connect each other and share experiences with each other.
[00:09:55.742] Kent Bye: Yeah, it makes me think of the medical implications of isolation and loneliness. And from a medical perspective, what kind of effects and impacts does it have on a culture when people are too isolated or lonely?
[00:10:07.352] Walter Greenleaf: It is a big problem. As the boomers are getting older, more and more of them are getting more and more isolated because they have chronic medical conditions, maybe a physical impairment. And isolation is, and they often aren't working and they're not getting out for that. So physical isolation is a big challenge and it's been shown clinically. that isolation does contribute to declining health, too. So you can hit a downward spiral, where if you're not connected to the community, your health declines, and then your health declines, and you're not further involved in your community. So keeping engaged is really important, and I think virtual worlds can keep our aging population a little bit more connected. We live all over the country now, and families aren't as connected as they used to be. So again, I think virtual environments can help bridge some of those gaps.
[00:10:52.317] Kent Bye: And finally, what's the best way for people to find more information about your work or get in touch with you?
[00:10:57.682] Walter Greenleaf: I guess just find me through LinkedIn, or it's Walter Greenleaf. WalterG at stanford.edu is my email address. And sure, get in touch with me. And I'd love to talk to people who are interested in collaborating. Great. Well, thank you. All right. Thank you.
