VIRTUAL REALITY THERAPY: Expanding the Boundaries of Therapeutic Recreation.

Therapeutic recreation specialists should give special attention to VR applications in health care settings and proactively examine their possible use in a therapeutic recreation intervention program.

Brandon balances precariously on a four-inch rock ledge, twenty feet above his belayer, wondering how he ever let his friends talk him into rock climbing. He is frozen in place, gripped by his fear of heights, afraid to move up or down. Frustrated, overcome with fear, and not sure what to do next, Brandon reaches out and turns the virtual reality simulator off telling the recreation therapist, "I'll try again next time."

Virtual Reality is the 3-dimensional (3-D) virtual world created with computer graphics, body-tracking devices, and head-mounted displays. Although Virtual Reality (VR) technology is relatively new, it has had considerable impact in industry and education (Grealy, Johnson, & Rushton, 1999). Currently, the virtual environments are moving out of computer science labs and into health care settings. Although VR applications in health care settings are limited, special attention should be paid to the potential that VR therapy holds as a therapeutic recreation treatment modality. This article has four primary purposes: (1) providing a basic introduction to VR, (2) sharing examples of VR therapy programs in the areas of mental health and physical medicine/rehabilitation, (3) examining the advantages of VR therapy, and (4) discussing the possible applications of VR to therapeutic recreation.

Virtual Reality

VR is a new human-computer interaction in which users are no longer simply external observers of images on a computer screen, but are active participants within a computer-generated 3-D virtual world. Rothbaum and Hodges (1999) point out that VR environments differ from traditional displays in that computer graphics and various display and input technologies are integrated to give the user a sense of presence, or immersion, in the virtual environment. The most common approach to the creation of a virtual environment is to fit the user with a head-mounted display. The sensory aspects of the virtual environment (auditory, visual, and tactile) are delivered to the individual through the head-mounted display. The sensory experiences depend upon the individual's movements within the environment, which are relayed back to the computer from the helmet sensor and other control devices (e.g., joy stick, the data gloves, or body suit). In short, VR integrates real-time computer graphics, body-tracking devices, visual displays, and other sensory input devices to immerse a participant in a computer-generated virtual environment (Rothbaum & Hodges, 1999). However, VR also comes in a `non-immersive' form in which sensory aspects of the virtual environment are presented on a conventional computer monitor and the individual controls his or her movement by means of a joy-stick or other control devices (Rose, Attree, & Johnson, 1996).

Development of VR systems that allow patients to move and grasp virtual objects could rapidly change the nature of rehabilitation programs (Grealy, et al., 1999). Within health care settings, medical applications for VR include surgical simulators, telepresence surgery, and rehabilitation. Mental health has had an increasing level of acceptance and implementation of VR as a viable treatment option among psychologists, clinicians, and therapists (Mahoney, 1997).

Virtual Reality has been identified as an effective modality for the treatment of many mental disorders. In 1995, Hodges and Rothbaum conducted the first controlled study of VR therapy in the treatment of acrophobia (fear of height). In their study, Hodges and Rothbaum developed height-related virtual environments (e.g., a bridge and a glass elevator). The virtual environment was proven an effective means of reducing subjects' acrophobia. Since that time, similar results have been reported in the treatment of other types of phobias, such as the fear of flying and the fear of spiders (Carlin, Hoffman, & Weghorst, 1996).

Olsen (2000) articulated that virtual reality therapy is effective for working with people with mental health impairments (e.g. chronic post-traumatic stress disorder and phobias) to overcome their difficulties. The applications of VR treatment, for this population, are based on the theory of desensitization. The use of VR provides the patients with the experience of being immersed in a three-dimensional simulation of the environment in which he or she was traumatized. For example, persons with acrophobia may receive treatment including repeated exposure to different levels of height. A patient receiving VR therapy may begin by watching others ride a virtual glass elevator, followed by the patient riding the elevator to the second floor of a building, and then on up to higher floors as the patient's comfort level increases. VR has also been used as a treatment tool for sexual offenders in psychiatric settings. For example, as in the normal treatment for most phobias, VR therapy involves systematically exposing, in measured amounts, phobic clients to the objects or situations they fear (Mahoney, 1997). For this to happen, the fear structure must be activated. VR is effective at activating the fear structure via confrontation with the feared stimuli, which elicits the fearful response. The feared stimuli cease to elicit anxiety in the processes of habituation and extinction (Rothbaum, 1999).

In addition to mental health, VR is also utilized in physical medicine and rehabilitation settings. The primary purpose of physical rehabilitation is to enhance physical functioning. However, clients with physical disabilities or illnesses are unlikely to have access to stimulating exercise opportunities needed for successful treatment. A client with a brain injury, who constantly reports feelings of fatigue, can ride a VR exercise bicycle in a stimulating, safe, and controllable setting. This setting may be more appealing than riding a regular stationary bike with no additional stimulus or riding on the street with an increased exposure to additional injury. Wilson, Forman, and Stanton (1997) cited the main benefits of VR for people with physical disabilities are that they can engage in a range of activities in a simulator, safely and relatively free from their physical limitations.

VR exercise programs can also be used to enhance cognitive abilities of people with brain injuries. According to Grealy and his associates (1999), clients with traumatic brain injuries who participated in a four-week virtual exercise program performed significantly better than a control group on cognitive functions such as digit symbol and visual learning tasks.

High levels of environmental interaction are likely to increase the potential for structural change within an injured brain. VR treatment has also been used with burn patients.

Strengths and Weaknesses

For both people with mental difficulties and physical limitations, VR offers a feeling of control over the environment (Rothbaum, 1999). In particular, many patients with physical disabilities or illnesses experience a feeling of learned helplessness related to their sense of control. They do not believe they have the ability to control their body and their own destiny. VR may provide these individuals with the power to create their own realities in the virtual environment (Glantz, Durlach, Barnett, & Aviles, 1997). By experiencing greater power in the virtual world, they could obtain increased perceived freedom and learn to have some power in the real world. They could also learn empowerment techniques that may be useful in a real environment.

Rothbaum and Hodges (1999) argue that VR is an efficient and cost-effective treatment for mental disorders, such as anxiety disorders. It may not be possible for hospitals to provide glass elevators or an airplane to treat patients with acrophobia (fear of heights) or a fear of flying, but in a virtual environment these experiences may be possible. VR is significantly safer than actual environments and it can be used with a high level of control in the situation. VR is also timesaving in that it can be used in the therapist's office or treatment setting. In addition, patients with phobias are more willing to enter a VR exposure than a real one because they know it is VR; however, they still experience many of the same responses (e.g., sweating, shaking) (Mahoney, 1997).

There are, however, some negative consequences of VR therapy. Some of the common ones include feelings of malaise, nausea, and physical discomfort (Mahoney, 1997). It could cause unintended changes in the patients' attitude and behavior, such as further complicating existing difficulty in distinguishing between reality and delusion (e.g., patients with schizophrenia). The applications of VR in medical and psychiatric settings are still being explored and very few controlled studies have been done to document their effectiveness.

Summary and Implications

This article briefly examined Virtual reality (VR) and discussed where, how, and why virtual reality therapies are being used (sample VR treatment studies are shown in Table 1). VR therapy is in its infancy, but it may hold tremendous promise in therapeutic recration in the near future. This new technology will provide remedial experiences that ameliorate various cognitive disorders and anxieties of clients in metal health settings. It will also yield new insights into rehabilitation mechanisms while providing creative and effective tools to re-enable people with disabilities.

TABLE 1. SAMPLE STUDIES/REFERENCES OF VR TREATMENT

Area              Authors/Date              What/Who was Treated?

Mental Health:    Kijima & Hirose (1993)    autistic children

                  Lamson (1994)             acrophobia
                                            (fear of heights)

                  Hodges and Rothbaum       acrophobia
                  (1995)                    (fear of heights)

                  Strickland, Marcus,       autistic children
                  Hogan, Mesibov, &
                  McAllister (1995)

                  Carlin, Hoffman,          fear of flying
                  & Weghorst (1996)         arachnophobia
                                            (fear of spiders)

Rehabilitation:   Nemire, Burke, & Jacoby   children w/spinal
                  (1994)                    cord injury

                  Weghorst, Prothero,       persons w/Parkinson's
                  Furness, Anson,           disease akinesia
                  & Riess (1995)

                  Grealy, Johnson,          persons w/Traumatic
                  & Rushton (1999)          Brain Injury

                  Olsen (2000)              burn patients

For VR therapy to be effective, a multidisciplinary approach is critical (Mahoney, 1997). That is, there should be a therapist, technical support people, and design experts to provide VR therapy. This new treatment approach may open up additional therapy opportunities, previously pursued in most cases by psychologists and medical doctors, for many health care providers and professionals. The door may also be opened to therapeutic recreation specialists who: are interested in using advanced technology; have the ability to combine their clinical knowledge with computer-aided technology, and; have the mind and desire to create new, innovative therapeutic recreation treatment modalities.

It seems obvious that therapy, such as VR therapy, will have direct implications for therapeutic recreation specialists who wish to employ technology to intervene with a wide variety of clients (Austin, 1999). VR holds promise as an innovative future therapeutic recreation treatment tool that could be used across a diverse array of settings and populations. Thus, it may be very important for therapeutic recreation specialists in the 21st century to be familiar with technology in order to more effectively seek innovative and effective treatment modalities within the context of recreation and leisure.

References

Austin, D. R. (1999). Therapeutic recreation: Processes and techniques (3rd ed.). Champaign, IL: Sagamore.

Carlin, A. S., Hoffman, H. G., & Weghorst, S. (1996). Virtual reality and tactile augmentation in the treatment of spider phobia: A case report. Behavior Research and Therapy, 35153-156.

Glantz, K. G., Durlach, N. I., Barnett, R. C., & Aviles, W. A. (1997). Virtual reality (VR) and psychotherapy: Opportunities and challenges. Presence: Teleoperators & Virtual Environments, 6 (1), 87-106.

Grealy, M. A., Johnson, D. A., & Rushton, S. K. (1999). Improving cognitive function after brain injury: The use of exercise and virtual reality. Archives in Physical Medicine and Rehabilitation, 80, 661-667.

Johnson, D. A., & Rushton, S. K. (1996). Virtual reality enriched environments: Physical exercise and brain injury rehabilitation. In P. M. Sharkley (Eds.), Virtual reality and associated technologies (p. 247-252). UK: The University of Reading Press.

Kijima, R., & Hirose, M. (July, 1993). Virtual sand box: A development of an application of virtual environment for the clinical medicine. Paper presented at the Third International Conference on Artificial Reality and Tele-Existence, Tokyo.

Lamson, R. J. (1994). Virtual reality of anxiety disorders. CyberEdge Journal, 4 (1), 6-8.

Mahoney, D. P. (1997, December). Virtual therapy nets real results. Computer Graphic World, 20 (12), 52-58.

Nemire, K. Burke, A., & Jacoby, R. (1994). Human factors engineering of a virtual laboratory for students with disabilities. Presence, 3, 216-226.

Olsen, F. (2000, September 22). Scholars in medicine and psychology explore uses of virtual reality. Chronicle of Higher Education, 47 (4), A46.

Rose, F. D., Attree, E. A., & Johnson, D. A. (1996). Virtual reality: An assistive technology in neurological rehabilitation. Current Opinion in Neurology, 9, 461-467.

Rothbaum, B. O. (1999). The use of virtual reality exposure in the treatment of anxiety disorders. Behavior Modification, 23 (4), 507-526.

Rothbaum, B. O., & Hedges, L. F. (1999). The use of virtual reality exposure in the treatment of anxiety disorders. Behavior Modification, 23 (4), 507-526.

Strickland, D., Marcus, L., Hogan, K., Mesibov, G., & McAllister, D. (1995). Using virtual reality as a learning aid for autistic children. Proceedings of the Autism France Third International Conference on Computers and Autism, 119-132.

Weghorst, S. W., Prothero, J. Furness, T., Anson, D., & Riess, T. (1995). Virtual images in the treatment of Parkinson's disease akinesia. Medicine meets virtual reality 11, 30, 242-243.

Wilson, P. N., Foreman, N., & Stanton, D. (1997). Virtual reality, disability, and rehabilitation. Disability and Rehabilitation, 19 (6), 213-220.

Virtual Reality holds tremendous potential for therapy, according to Heewon Yang and Raymond Poff, authors of "Virtual Reality Therapy: Expanding the Boundaries of Therapeutic Recreation". Yang is a Ph.D. candidate and associate instructor in the Department of Recreation and Park Administration at Indiana University. He received a B.S. in Forestry from Korea University and a M.S. in Recreation, Leisure, and Hospitality from the University of Tennessee, Knoxville. His primary concern is developing theory-based therapeutic recreation intervention programs for adolescents with aggressive behavior and conducting outcome studies on the intervention program. Poff is a Ph.D. candidate and associate instructor in the Department of Recreation and Park Administration at Indiana University. He has a B.S. in Recreation Management from Brigham Young University and a M.S. in Recreation Administration from Indiana University. Poff is the former Recreation Coordinator of BYU Outdoors Unlimited, one of North America's largest university-based outdoor programs. His primary research interests center around leisure involvement and commitment.