#571: PTSD Exposure Therapy in VR: Importance of Storytelling & Emotional Presence in Healing from Trauma

skip-rizzoDr. Skip Rizzo heads the Medical VR Research Group at USC’s Institute for Creative Technologies, which has been exploring how to use VR for psychological treatments, cognitive assessment, motor rehabilitation therapy, as well as interactions with virtual humans. He’s been on the forefront of using virtual reality to treat soldiers with post-traumatic stress disorder with virtual exposure therapy. VR is used to incrementally trigger an embodied sensory experience in PTSD patients by placing soldiers within the virtual sights, sounds, feelings, and smells of common combat scenarios in Iraq and Afghanistan. This virtual exposure therapy stimulates the original embodied experience of traumatic events for soldiers so that they can connect to specific details of their memories so that they can do a process of cognitive restructuring by telling the story of their experience. Rizzo says that a key component of healing from PTSD is if the patient is able to connect to the underlying emotions of the experience while sharing the narrative of their experience, and that this can unlock a cascade of healing effects that USC has been able to measure over the years.


I had a chance to try out a demo of the VR PTSD Exposure Therapy project during a reception at USC ICT during the IEEE VR 2017 conference in Los Angeles in March, and was struck by their holistic multi-modal approach of using subwoofers, smells, and passive haptic guns. I caught up with Dr. Rizzo to talk about his work in using VR to heal from PTSD, the importance of storytelling and emotional presence, and their future work in expanding treatment scenarios for victims of Military Sexual Trauma, and moving into civilian trauma with first-responders like police and firemen. He also talked about an episodic, interactive storytelling experience that will be like an emotional obstacle course of navigating different traumatic scenarios with the help of a virtual human that is helps guide the patient through the cultivation of coping skills for stress management, mindfulness techniques, and cognitive reappraisal. This work at USC ICT shows that immersive virtual environments can stimulate a deep sense of embodied and emotional presence that has vast healing potential that goes well beyond just the gaming and entertainment applications.

Here’s a 20-minute VICE Canada Story on Virtual Reality PTSD Exposure Therapy

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Rough Transcript

[00:00:05.452] Kent Bye: The Voices of VR Podcast. Hello, my name is Kent Bye, and welcome to The Voices of VR Podcast. So over the last couple of weeks, I found myself talking to a lot of people who had never heard of virtual reality and didn't really know what it was. So I found myself fighting against this word virtual, because it implies fake or not real. people immediately start to contrast what they know about technology and addiction to cell phone use and they immediately extrapolate out and think oh my god this is going to be absolutely terrible that now we're going to get even more immersed and addicted and escaping into these fantasy realms. There's no denying that the potential for that is there but what I found personally with virtual reality is that it's actually a technology that gets me more present into life and living A lot of technology is abstracted into the mind and dissociative in different ways. And you can very easily escape into these different portals through the windows of your cell phone. And there's something about virtual reality that actually gets you more present in your body and potentially even within your emotions. And I found myself talking about a lot of the amazing healing potential of virtual reality when it comes to either curing yourself from lazy eye or healing yourself from post-traumatic stress disorder through exposure therapy in VR. So on today's episode, I talked to Skip Rizzo, who's in charge of the medical VR research group at the USC Institute for Creative Technologies. And we do a deep dive into healing from PTSD with virtual reality and how so much of it is about being able to tell the story and to be completely connected to your emotions around it. And that is the thing that kind of unlocks and unleashes all sorts of cascading effects that can put people on a path towards healing that is at least as effective as using your imagination, and in some cases, even more effective. So that's what we'll be covering on today's episode of the Voices of VR podcast. So this interview with Skip happened on Monday, March 20th, 2017. And it was a part of the reception for the IEEE VR Academic Conference that was happening in Los Angeles, California. So with that, let's go ahead and dive right in.

[00:02:16.133] Skip Rizzo: My name is Skip Rizzo. I direct the Medical Virtual Reality Research Group at the USC Institute for Creative Technologies. And my focus in VR over the last 20 years, starting the lab in 1996, has been for clinical virtual reality applications. So this has spanned the range from psychological treatments, like what you've seen with some of our PTSD work, to cognitive assessment and rehabilitation, working with kids with attention deficit disorder, actually running a study back in the late 90s with people with Alzheimer's disease. Also, working in the area of motor rehabilitation, physical and occupational therapy, following a stroke or a traumatic brain injury. And then finally, the fourth area that our lab focuses on is the use of virtual humans for clinical applications, whether it's for building virtual patients that novice clinicians can practice on, you know, mess up a bunch with a virtual patient before you get your hands on a live one. or virtual human support agents that can reside on your phone or on the internet that can help you find healthcare information.

[00:03:28.051] Kent Bye: Yeah, and I had a chance to actually go through one of the PTSD exposure therapy sessions where I'm riding around in a Humvee and there's different haptic effects with the explosions and holding a gun. Maybe you could talk a bit about what you've been able to show in terms of using exposure therapy within a virtual reality context.

[00:03:48.576] Skip Rizzo: Well, the literature thus far has been quite positive. You know, we're already starting from an evidence base where we're using a methodology that's been used for 20, 30 years in a traditional format where using imagination alone, the patient goes back and confronts and processes these very difficult emotional memories. What we do is take that same evidence-based approach but deliver it in VR where we can put people in customized scenarios and help pace the exposure or the confrontation and processing of difficult emotional memories at a pace that the patient can handle and in a way that emotionally engages them with this. Now, a lot of times when I first described this, people think, why the hell would you do that? It's like torture. But the scientific literature and the clinical application of this shows that by doing this repeated confrontation and processing at a pace the patient can handle in the safety of the clinical environment, we see dramatic reductions in PTSD symptoms, not only as measured by self-report of symptoms, but also in terms of psychophysiological reactivity, neuroendocrine reactivity, cortisol reuptake rates, Things like that that are good markers, that are objective markers of change that go beyond what a patient might tell you. We've also, working with Mike Roy at Walter Reed, he did a study where he looked at fMRI data of PTSD patients before and after exposure therapy. and found changes in the activation level of key areas of the brain that are involved in the fight-or-flight response, like the amygdala area of the brain, versus the frontal lobe area, which tends to be a modulating organ, if you will, modulate the emotional reactivity that oftentimes is hyper-accentuated in people with PTSD.

[00:05:48.938] Kent Bye: And so it seems like there's a dimension there of just getting exposed to the stimuli that they've been through. But is there also a component of storytelling? Or what do you think it is that's actually kind of unlocking and really moving through the trauma?

[00:06:02.523] Skip Rizzo: This is a really good point that you bring up, the idea that storytelling is curative in and of itself. And I think, you know, when we think about our past experience, if we can't put it into a cohesive narrative that we can share with people, then it just hangs in there. It's amorphous. It's like a hidden trauma that you can't come to grips with. What we do in the therapy is, the VR isn't just like automatically fixing people. It's just a stimulus context to spur on the narrative. So the patient sits there and basically will tell their combat narrative as if it's happening right now. And they'll retell that story. And while they're doing that, the clinician is updating in real time the elements of the virtual environment. So it mimics what they had experienced in the story that they're telling. By that process, what happens is What starts off as a very sanitized, cognitive retelling of a story, as you get more emotionally engaged in it, you start to hear the emotion come out. So instead of the story being the first time through, like we were driving in a Humvee, we were approaching a village, hit an IED, my best friend died, end of story. Therapist got his work cut out for him, says, okay, let's take it back 10 minutes. Tell me about your best friend. You know, what were you talking about? You know, what was he like? You know, what were you thinking? What were you feeling as you were approaching that village? And as you go through this in the simulation and as a patient is telling a story, now these emotions that have been kind of pushed below the surface start to bubble up. And admittedly, it's hard medicine for a hard problem. And we tell patients it's going to get harder before it gets easier. But by going through this process in a safe place with a good clinician that knows how to do this work, you see dramatic decreases in anxiety responding and more of a sense of empowerment that people can now go through these things. They can talk about the things that have been haunting them, that they couldn't put into words before, that they never talked to anybody about. And I think you get a multi-pronged therapeutic effect when you do this kind of therapy. But certainly when people first hear about it, They see what we're doing. If they don't understand the scientific principle that underlies this kind of treatment, they think, oh God, why are you torturing that poor guy? Leave him alone. But the data seems to support that. A number of published studies that have shown pretty much every one of them has shown clinically meaningful as well as statistically significant reductions in PTSD symptoms following treatment. Now, compared with the original approach and imagination alone, we've had many patients that have gone through that with no benefit and then come to us and then do achieve benefit. We've run comparisons. One comparison showed equivalent effect at post-treatment, recently published study in the Journal of Consulting and Clinical Psychology. But other studies with smaller sample sizes have shown VR outperforming the traditional method. So, you know, the challenge with the one that showed just simply equivalence, which is fair enough. I mean, it's another, now we have an evidence-based approach equivalent to the existing top-line treatment. But that was using a very limited scenario. That was a system we had built originally that had only four scenario options. Three of them were driving, one of them was a foot patrol. After using that for a number of years, we learned what the gaps were, what we were missing, and it turned out We needed more diverse content. The detail was sufficient. It's a diversity that was needed. So we built out a remote Afghan village. We built out a forward operating base in the mountains so that you could experience more incoming mortars in that setting. an industrial zone, different village types or marketplace types. So we learned from our patients, you know, really user-centered design where we learned from the first version what we needed to do better in the second version.

[00:10:16.988] Kent Bye: And so it sounds like there's these kind of archetypal experiences that different veterans have gone through, depending on whether or not they were in Iraq or whether or not they were in Vietnam. I know I've talked to some researchers who said the Huey helicopter and the sounds of being transported in the helicopter was a big common experience that a lot of people who were in Vietnam had experienced. And so it sounds like with the virtual reality immersive technologies, they're creating a somewhat of an embodied presence, but yet it sounds like you're trying to cultivate this sense of real deep emotional presence and connecting to the emotions of it. And not just dissociating until the story disconnected from your body, but really being within your body and being able to really work through that emotional cathartic release.

[00:11:00.112] Skip Rizzo: I think in the service of trying to raise that emotional engagement, we've tried to go multi-sensory so that, you know, we can create that embodied experience. So we run the sound through subwoofers, amplified through subwoofers in the floor. So as a user's driving a Humvee or an MRAP or a bomb goes off, you can feel the concussive force of the bomb or the vibration of the motor. And it goes through your body. It creates a body sensation of being there. We also use a smell machine. And this scent machine that we employ delivers pretty nasty smells. Things like body odor, burning rubber, rotting garbage, diesel fuel, cordite gunpowder, things like that. You know, not good smells, but smells that bring people back to the scene very rapidly. Honestly, the synthetic smells we use, I have a hard time differentiating them, but I don't have such a good sniffer. But for somebody that lived through that kind of experience, those smells bring them back instantly. And we see that the area of the brain that handles scent, where the olfactory bulb connects up in the limbic system, is very tightly related to memory and emotion. And so we can activate that deep emotional memory through the thoughtful use of synthetic smells to help a patient to really go back in a deep and an embodied way.

[00:12:27.214] Kent Bye: Can you get it without people really connecting to their emotions? Do you feel like that's a key part of this healing process?

[00:12:34.297] Skip Rizzo: The research prior to VR showed that people that don't emotionally engage while they're relaying their trauma narrative, while they're talking about it, usually have poorer outcomes. And the way they measure that is like the simple skin conductance, galvanic skin response. So if somebody is there saying, OK, I'll tell you the worst thing that happened to me, and they start telling their story, but you're not seeing any physiological reactivity that reflects emotional changes. Those are the people that show poorer outcomes. And that was one of the drivers for why we wanted to go with VR. Because VR is an emotionally evocative technology. And what you find is that if you can activate those emotions, a whole cascade of events happen, whether it's physiological, emotional, or just in their narrative. You know, I think that what we tend to see is that for people that don't emotionally engage in their trauma narrative by imagination alone, and mind you, avoidance of memories and places is one of the cardinal symptoms of PTSD, And so it's maybe a pretty tall order to ask somebody with PTSD to really graphically visualize what they went through while they're telling a story. And I mean, their whole life they're spending trying to detach themselves from those bad emotions. And so this is where I think VR has the added value and why we've successfully treated people that didn't benefit from traditional imaginal only therapy is that we can activate those emotions. And again, it's hard medicine for a hard problem. But if people stick with it, and we don't reinforce avoidance, we reinforce confronting, talking about it, rolling with it, but you're in the safety of the clinical environment, that's when you see the positive outcomes.

[00:14:34.582] Kent Bye: Do you have any stories or anecdotes of people who have gone through this treatment that you think really represent the power of VR and healing from PTSD?

[00:14:46.465] Skip Rizzo: Well, every treatment has its star patients. And we've got a couple of them. And I have a YouTube channel under my name that if you went up there, you would see probably eight or 10 media clips, one from CNN, another one from Vice, where some of these patients report what they went through. And there's a common pattern with all of these patients. And the pattern is, I came back. I didn't want to admit I had a problem. I wanted just to go back because I felt more right over there than I felt in civilian life, but I couldn't go back. So I tried doing this job and that job and I tried to be a police officer and that didn't work out. Anyway, the template for the story really is I didn't want to admit I had a problem. I felt I was being weak. But eventually, it just got to be too much. And fortunately, I tried a couple of therapies with no benefit. But then all of a sudden, I found this one. And it puts you right smack dab right back in the middle of it again. And it's like cleanup. And so you hear people talk about the initial step of avoidance, and the initial step of trying to cope day-to-day, and the angry outbursts, and the family members that take the brunt of it, and then finally some switch gets flipped, and they ask for help. And fortunately, when they asked for help, this time they got into, you know, one of our trials or a site that had our stuff. and they benefited from it and you know I don't want to put the words I don't want to try to describe what they say because it'll sound like we're bragging I think if you go to our YouTube channel and listen to some of the stories firsthand you'll see you'll see heartfelt descriptions of that epic challenge that journey going from the hell of war to another hell in civilian life and then transitioning forward and getting past it.

[00:16:55.055] Kent Bye: So I'm curious to hear if there's other domains that you feel like suffer from a lot of PTSD. I realize with veterans, they have these archetypal experiences that you can kind of generally cover a big area of people. But PTSD and trauma is wide and varied. People have gone through all sorts of different trauma. So I'm curious sort of what the next frontier for you is in treating PTSD with VR.

[00:17:22.402] Skip Rizzo: I see the direction of our work moving towards applications for civilian trauma. We're already working with military sexual trauma. We've modified the environments, created more civilian context, because most sexual trauma in the military doesn't happen in the trenches of Afghanistan. It's happening outside and around U.S. military bases. We built a small town with a bar and an alley and parking and a car and motels and malls and office spaces and bedrooms and military base type content. And we're applying that now in a clinical trial at Emory University. And thus far, the first six patients are showing clinically meaningful improvements across the course of treatment. If that continues, then we'll be well poised to address sexual trauma in the civilian population. Now, this is more Hitchcock than Hurt Locker. We're not blowing things up and we're certainly not creating virtual sexual assaults. We're creating the context in which these things happen and based on many experiences where we've interviewed sexual trauma victims and they describe, you know, what they went through. And so we got good coverage. So I'm aiming towards, if the data continue to show success, I want to advance that research to the civilian sector for civilian sexual trauma, but also look at other members of what I call the urban battlefield, police, firefighters, first responders, civilian victims of terrorist attacks. Before we did this work, Joanne DeFede at Cornell Weill had done work with World Trade Center victims using VR and showing good clinical gains. So I see, unfortunately, a lot of trauma in the world, but I think we can address it and make this treatment more available and normalize the treatment so that people look at it like a toothache. You know, when you have a toothache, you don't have any compunction about it. going to the dentist. Nobody likes going to the dentist, but you're going to go and get your tooth fixed. We want to make it the same way to de-stigmatize the feeling of pain that people feel that doesn't go away when they have PTSD after the trauma continues and it goes on and people don't have to live with that. So we want to try to expand the technology in that area. We're working with a group in France to build out the Paris areas for the terrorist attacks. We can't find funding to get that thing going, so we're working on the backs of graduate students to create it. But it's moving along. and I expect that we'll be able to do more in that area. I also expect we'll be able to do more for people in high-risk professions in pre-deployment resilience training using VR. We've done this with the military already where we use our VR simulations and we put people in immersive interactive stories where they're part of a mission instead of watching Band of Brothers on TV or in the Band of Brothers episode in VR. And at the end of each episode, something bad happens, and the bad thing is modeled after the things that PTSD patients report to be the things that haunt them. Well, that's sort of like an emotional obstacle course, but we don't just stop there. At the end of the bad event happening, a virtual mentor walks out and guides you through training in how to cope with adversity, stress management tactics, mindfulness tactics, cognitive reappraisal. all the things that we typically do to prepare people for difficult events in the future, but we do it in the context of an emotional experience that's relevant to what you may be facing when you go into combat. So I see those as, when you're talking about trauma, I see wider spread translation to civilian populations and better preparation for traumatic events in advance to try to reduce the incidence of PTSD later on.

[00:21:21.897] Kent Bye: Great. And finally, what do you see as kind of the ultimate potential of virtual reality and what it might be able to enable?

[00:21:31.161] Skip Rizzo: Well, I felt this since the first wave of excitement about virtual reality back in the early to mid-90s when I first got hooked on it. And now the second wave where the technology's caught up with the vision and we can really do good stuff. I see VR as having a dramatic impact, not just on mental health, but rehabilitation and wellness and other pro-social areas, education, journalism. things that make a difference for people so that we can leverage what people do in a virtual world to make their interactions in the real world more effective, better, pleasurable, enjoyable, more of learning experiences. So I see the future of VR not just being about gaming. I mean, thank God gaming is there because it provides the market to drive all the innovation. And we wouldn't be where we're at today with the technology if it wasn't for the game industry. So thank God for that. But VR can go well beyond just providing entertainment. It can provide enrichment. It can provide wellness. It can provide treatment. It can provide education. I think we can make a difference in the real world by thoughtfully constructing experiences in the virtual world. Awesome. Well, thank you so much.

[00:22:49.562] Kent Bye: Pleasure. Thanks for having me. So that was Dr. Skip Rizzo. He's the head of the Medical VR Research Group at the USC Institute for Creative Technologies. So I have a number of different takeaways from this interview is that, first of all, it seems clear from Skip that a huge component of healing from traumatic events and PTSD is to be able to connect to the narrative and the story of the experience, as well as to really connect to all of the emotions that are surrounding that event. And that when you can do that, then it kind of unleashes a cascade of other effects that puts you on the path towards healing. The other part is that it seems like there's a pretty huge part of the somatic experience that is key in terms of unlocking these stories and narratives. It's almost as if the trauma is stored within the cells of your body and in order to get it out you have to either be triggered and then dive into a narrative. It's this process of cognitive reappraisal where you're able to take these disparate or fragmented or ignored parts of the story and to be able to actually make new meaning around them so that you can connect to the story around it but also express your emotions around that. So there's a huge, huge component to both this emotional presence as well as embodied presence when it comes to healing from trauma. And the thing that's different about VR is that rather than just using your imagination to connect to these visceral feelings, you're connecting to visuals that may be putting in you there. So they have to create almost like these archetypal experiences that are reminding you of all the sounds and the visuals that you may have experience while you're either in a Humvee and there may be an IED explosion or if you're in your camp and there's incoming mortars and that there's explosions when the explosions happen they have these visceral bass that just vibrates your whole body and as well as the smells and so they're trying to trigger as many sensory cues as they possibly can so that you know the goal is to not just put people through this experience it's super intense But, you know, they have like different dials where they're able to kind of slowly dial up the different stimuli and have people, you know, get comfortable and used to going into these different experiences. So that's not too much at any given time, but they can slowly expose them to the stimuli and then eventually get them connected to their story and their narrative. So they can eventually not just recount the facts and the data of what happened, but to really connect to the emotions of the entire experience. And that seems to be something that can really unlock and heal from trauma. So to me, that's just a huge component of being able to both craft and tell your story while you're emotionally present, but also have that be witnessed by other people so they can hear that. And right now, they're starting with a lot of the military PTSD traumas, just because a lot of those specific traumas have these very universal things that people go through. When I talked to Larry Hodges, he said that, you know, in Vietnam, it was a Huey helicopter, that a lot of the soldiers had that as kind of the universal experience that a lot of people had. And for these wars, either in Iraq or Afghanistan, it's being in the desert, riding in a Humvee, and maybe having IED explosions. But that's not everybody's trauma. And so as they move forward, they're going to be fleshing out the different scenarios that may be triggering specific traumas that people have gone through. And in terms of the sexual traumas and sexual assault and rape, Skip said that there's a whole class of what they call military sexual trauma, and that again, the common archetypal experiences are pretty similar. But once they get that down, then they're able to potentially abstract that out and move that into generalized sexual assault, harassment, or other sexual traumas, and to move that into the civilian population. And the other demographics are first responders, cops, and firefighters, who are also going through all sorts of crazy trauma day in and day out. And finally, I just wanted to recount the four major areas that Skip said that their lab is looking at when it comes to healing using virtual reality technologies. And that's the psychological treatments like PTSD that we talked about pretty much focusing on this interview exclusively. But there's also things like cognitive assessment and rehabilitation to be able to treat people with ADHD or neurodegenerative diseases. There's also motor therapy and being able to do neuro rehabilitation, be able to send in signals into the brain to heal from strokes. And finally, there's using virtual humans for clinical applications. And so, you know, one of the scenarios that he said at the end, I thought was really fascinating was that they're kind of moving into this interactive narrative and story where there's these different episodes that people go through. And at the end of the episode, there's some sort of like dilemma or trauma that you experience. And then you kind of get into this triggered state of trauma. And then there's a virtual human that comes out that starts to give you guidance as to how can you deal with this? What are some coping mechanisms? stress management or mindfulness based techniques or cognitive reappraisal. And there is this virtual human that's guiding you through all of this and giving you the skills that you need within the context of a trauma or a narrative. And that it's kind of episodic where you are able to go what he called it as like this emotional obstacle course to be trained how to cultivate the different coping mechanisms that you need in order to deal with these various traumatic situations. So yeah, to me, it's super clear that VR is not just a toy. It's not just for gaming and entertainment, but there's all sorts of super profound applications when it comes to education, medicine, journalism, enrichment, and general improvement of your wellness. So that's all I have for today. I just wanted to thank you for listening to the Voices of VR podcast. And if you enjoy the podcast, then there's a couple of things you can do. Just spread the word, tell your friends, and become a member to the Patreon. Just a few dollars a month makes a huge difference and allows me to continue to bring you this type of coverage. So you can donate today at patreon.com slash Voices of VR. Thanks for listening.

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