Use of Tethered Virtual Reality Headsets in Exposure Therapy for Agoraphobia and Social Phobia Beatris Mariell Choo, Ana Margarita Talicol, Elaine Jhon Panganiban, Ethel Chua Joy Ong De La Salle University agoracademy@gmail.com Abstract console, or mobile VR devices that are reliant on a smart- phone for both display and processing, VR has been used for People with social phobia are characterized by a many things such as video games (Farlands [Oculus, 2017], fear of being scrutinized, while people with agora- Resident Evil 7 Biohazard [Capcom, 2017]), training simula- phobia have a fear of situations where escape may tion (High Voltage Switching [Computing, 2017], Virtual Re- be difficult such as being in a crowded area. One ality Crane & Rigging Simulations [International, 2017]), and way to support them is with the use of virtual re- healthcare (Bravemind [Rizzo et al., 2010]). Under health- ality technologies. Virtual reality (VR) allows peo- care, VR has been widely used to treat specific phobias, such ple to easily step into and immerse themselves in as acrophobia [Emmelkamp et al., 2001] [Rothbaum et al., a completely different environment, simulated by a 1995] [Krijn et al., 2004], fear of flying [Baños et al., 2002], computer. The ability that VR has to transport a arachnophobia [Cavrag et al., 2014] and fear of cockroaches person into a different place and interact with the [Wrzesien et al., 2013]. However, it is uncommon to use VR virtual environment gives it potential as a tool for for therapy of other types of phobia, such as social phobia. phobia treatment. In this paper, we explore the use Exploring the application of VR in treatment of social pho- of VR as a platform for people with agoraphobia bia and agoraphobia may uncover and answer questions about and social phobia to practice social interactions to- the impact of interactions with virtual humans on therapy pa- wards the goal of overcoming their fear. tients, especially with the increased immersion provided by the tethered VR headset. In this paper, we present our work 1 Introduction in developing a virtual reality environment as a platform for Social anxiety disorder, also known as social phobia, is the people with agoraphobia and social phobia to practice social fear of scrutiny from others [World Health Organization, interactions towards the goal of overcoming their fear. 2016]. Situations such as meeting new people, being ob- served by others, and performing in front of a crowd can trig- 2 Related Works ger this fear. People suffering from social phobia fear being A way to treat social phobia is by having the patient undergo thought negatively of by others, getting humiliated, embar- cognitive behavioral therapy (CBT). CBT is the combination rassed, or being rejected [American Psychological Associa- of techniques from cognitive therapy, in which the therapist tion, 2013]. They tend to avoid social situations as a result of focuses on changing the patients perception over something; this and thus affecting their way of living. and behavioral therapy, where the therapist instead works on Agoraphobia, on the other hand, is the fear characterized how the patient reacts to things [Lorenzo-Luaces et al., 2016]. by situations in which the person perceives to be difficult to CBT consists of four major variations: exposure, cognitive escape from if needed. It is highly recommended for peo- restructuring, relaxation training, and social skills training ple with agoraphobia to have a companion with them, spe- [Heimberg, 2002]. Each variation focuses on a different as- cially when going out. Situations that may trigger their fear pect. For exposure, the focus is on having the patient face include: using public transportation, being in open spaces, their phobic stimuli. Cognitive restructuring focuses on hav- being in enclosed places, standing in line, being in a crowd, ing the patient reevaluate the way they think about a situation and being outside home alone [American Psychological As- and then develop a different way of thinking towards it. Re- sociation, 2013]. Like social phobia, agoraphobia can affect laxation training teaches the patient how to relax certain mus- the way a person lives. In severe cases of agoraphobia, the in- cle groups in their body. Finally, social skills training focuses dividual may completely refuse to go outside of their homes on addressing the behavioral deficiencies that a person with [American Psychological Association, 2013]. social phobia may likely have, such as poor eye contact and Virtual reality (VR) is a computer simulated environment having poor conversational skills. whose goal is to immerse the user in an environment that is While VR is lauded for its ability to allow humans to do different from what they already have around them. Using or experience something that is normally impossible, VR in head mounted displays that are either tethered to a PC or a therapy exists primarily because VR allows users to indulge 20 in everyday experiences that they cannot perform normally because of their condition. For example, a VR environment created for confined or bedridden patients may feature scenes where the patient is traveling from one place to another [VR Kids, 2015]. VR environments in therapy vary in their like- ness to the real world; therapy environments for young chil- dren often involve the use of animal-like companions [VR Kids, 2015] while therapy environments meant for adults are more realistic and attempt to mimic true experiences [Rizzo et al., 2010] [Freeman, 2008]. Bravemind [Rizzo et al., 2010] is a therapy tool made to recreate situations a soldier would encounter in war. The scenery was made to resemble areas such as Afghanistan or Iraq, in areas where the solder may have encountered trau- matic experiences. While Bravemind employs the use of a Figure 1: A view of the virtual classroom virtual reality headset, the soldier is asked to stay seated and navigates the environment using a handheld controller. The situations and encounters within the environment are fully to a virtual environment resembling a small school. In the controlled by a therapist using a separate device. school environment, there are four main areas: a cafeteria, a [Freeman, 2008] created a simulation to test for symptoms classroom, as seen in figure 1, a hallway and a teacher’s of- of paranoia. The 4 minute simulation required the patient to fice, which will be populated with virtual students, teachers ride a virtual version Londons underground train from one and staff. These areas were selected because of their age neu- station to another. Afterwards, the patient was asked to com- trality, as opposed to an area such as a playground, which may plete a series of assessment reports about their experience. not be appropriate for older students, and because of the range The results from the assessment reports were found to have of social interactions that can happen in these environments. been able to predict symptoms of paranoia from physical as- Interactions in the virtual environment happen in the form of sault victims over the period of half a year. A separate study conversations between the patient and the virtual humans. using the same simulation found that the simulation did not Before beginning the implementation, an ethics review was produce any unwanted effects on the individuals involved in performed in order to ensure the safety of the participants the testing. It was also concluded that the simulation was ef- who may be involved in testing the system. A licensed psy- fective in eliciting reactions that the individuals would have chotherapist provided their guidance to the researchers during had if they were undergoing a real life train ride [Fornells- the design and implementation processes. Ambrojo et al., 2008] The Oculus Rift has been selected as an interface for in- [Baños et al., 2002] studied the effects of a VR therapy creased immersion and for the use of hand gestures. This treatment for the fear of flying. The environment allowed will allow the environment to come across as more realistic the patient to undergo multiple scenarios that may trigger a to the patient. Using voice input, room-scale VR navigation, phobic response regardless of whether or not the patient was and hand gestures, the patient is expected to explore the envi- actually inside a plane. The researchers involved in the study ronment and perform various social interactions that they are asserted that regular exposure therapy for the fear of flying normally unable to perform. is expensive and impractical, and justified the need for VR When the patient first uses the system, they will be asked treatments in exposure therapy. to provide their name, year of birth, gender, and preferred These studies have shown that VR has been effective in gender for a virtual peer. This data, which are henceforth be assessing symptoms of and treating different mental illnesses, referred to collectively as the patient profile, will be saved and and therefore allow for the assumption that VR can be used made available for viewing by the psychotherapist later. to treat social phobia and agoraphobia. To address social phobia, the patient will be presented with a number of social situations that they may encounter in school, such as introducing one’s self to a teacher, ordering 3 VR for Social Phobia and Agoraphobia food from a canteen, or talking to a classmate. Each situa- According to [K Beesdo K, 2009], the first onset of anxiety tion is referred to in the system as an event, and each event disorders can happen as early as the childhood or adolescent may have a prerequisite event that the patient may need to age. Anxiety disorders may also develop following traumatic complete beforehand. The patient will be “placed” in the en- events. An adolescent may experience trauma if they are the vironment and will be asked to perform the selected event’s victim of bullying in school, and may develop a phobic re- task. There are six events currently defined in the environ- sponse to school-related situations because of this trauma. ment. Table 1 shows a list of these events and where they Students may exhibit symptoms of agoraphobia and social take place. phobia [American Psychological Association, 2013], such as To address agoraphobia, the system will attempt to adjust avoidance of the school-related situation unless accompanied the number of virtual humans in the school according to the by a peer, as a result. patient’s anxiety level. Before and after the exposure proper, To aid in treating these symptoms, the patient is exposed the patient will be asked for their anxiety level on a scale of 21 Event Name Location lic consumption, it was minimized by re-mapping the areas Introduce to teacher Classroom of the virtual environment to match the playing area of the Introduce to classmate Classroom VR device in such a way that the patient need not step out Introduce to class Classroom of bounds. Additionally, it is recommended that a compan- Ask anyone for the time Anywhere ion stay with the patient in order to ensure that they do not Order food from the cafeteria Cafeteria encounter any accidents while using the VR headset, which Paying for tuition Office obscures their vision of their surroundings. Lastly, the weight of the tethered headset may cause er- Table 1: Events in the virtual environment gonomic problems to the patient if it is worn for an extended period of time. In order to prevent fatigue, each individual 0 to 10, or their SUDS score. The SUDS score taken before session was designed such that it would last no longer than the session is used to generate the environment and will be in- an hour. This restriction, however, presents a detraction from versely related to the crowdedness of the environment; that is, a real life exposure session, which may normally last longer the higher the SUDS score, the lower the number of people in than an hour. This detraction implies that there may be a dif- the environment. Through exposure and conversations with ference between the patient’s reactions and behaviors inside the virtual peers in the environment, the patient is expected to the virtual environment than the data that would be collected gradually be able to adapt to different social environments. if the patient encountered the situation in real life. For ex- There will be a virtual peer who can guide the patient ample, the patient’s behaviors if they are asked to wait in an through the tasks to provide, at the very least, a familiar face office for an extended period of time, or the patient’s behav- in the crowd of otherwise automatically and randomly gener- iors if they are asked to sit in a 90-minute class will not be ated virtual humans. By clenching both their fists, the patient monitored beyond the first hour. may indicate to the virtual peer that they are feeling over- whelmed. The peer will then guide the patient through a re- laxation exercise that can help the patient calm down. The 5 Ongoing Work patient may then decide whether to continue with the expo- sure proper or to end the exposure proper early. In this paper, we discussed the work we are doing to inves- The design of the system presents an opportunity to collect tigate the potential use of virtual reality systems in exposure data about the behaviors of the patient during the exposure therapy for people with agoraphobia and social phobia. Since proper. Apart from the patient profile, the SUDS score before these anxiety disorders occur at an early age, we designed our and after each session are collected. Those sessions whose environment to simulate places, activities, events and interac- SUDS score is higher at the end than it was at the beginning tions in a school setting. will be tagged and the psychotherapist can prioritize review- At present, we are processing needed documents and un- ing these sessions. All conversations between the patient and dergoing ethics reviews with relevant individuals in our uni- virtual humans will be also recorded. A list of keywords that versity and partner hospital to ensure that field testing with may indicate that the patient is at risk of harming themselves patients will go smoothly. The virtual humans are also under- or others has been compiled. Any conversations containing going remodeling while the integration with the Oculus Rift these keywords will again be marked and recommended for is undergoing usability testing to create a more realistic and review to the psychotherapist. Lastly, the system will col- immersive experience for the patient. lect data about how the session was ended, and the number Assuming that a professional can supervise the therapy ses- of times the virtual peer facilitated a relaxation exercise for sions and guide a cooperative patient, there is evidence to the patient. All collected data will be made available for the show that VR-based solutions has a positive effect on treat- psychotherapist to review and use. ment [Rizzo et al., 2010]. The validity of these findings to our system will be determined through actual testing with 4 Issues Encountered participants who will be recommended by the psychothera- Because only a microphone and the Oculus Rift peripherals pist. These participants are students who have been diagnosed are used to take input, the system is unable to detect whether with mild agoraphobia and social phobia, and should have un- the patient is becoming overwhelmed by the environment. dergone cognitive behavioral therapy. It should be noted that This information is needed in order to prompt the virtual peer the system is meant as a support tool for exposure therapy, to step in and facilitate an exercise to help the patient relax. and should be evaluated as such. The psychotherapist should Therefore, in lieu of other peripherals meant to detect anxiety retain his/her control over the use of the tool by supervising, or fear, hand gestures will be the means by which the patient designing and reviewing treatment sessions. can prompt the virtual peer. Future research can use the data collected during the ex- The presence of wires also poses a problem as the patient is posure therapy sessions to discover patterns in behaviors of expected to walk around in the environment. This restricts the patients suffering from and trying to recover from agorapho- patient’s movements within the environment, and may cause bia and social phobia. The use of other wearables to detect issues in tracking the location of the patient in the environ- heartbeat or sweat levels to determine anxiety or fear, and use ment. While this issue is unavoidable as wireless tethered this to adjust the environment dynamically as the patient un- headsets for VR have not yet been made available for pub- dergoes the exposure proper can also be explored. 22 References Rob Mclay. Development and early evaluation of the vir- [American Psychological Association, 2013] American Psy- tual iraq/afghanistan exposure therapy system for combat- chological Association. 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