The Virtual Reality Medical Center
One of the most unique uses of the 3D chat application known as OnLive! Traveler has to do with the work at VRMC, the Virtual Reality Medical Center at San Diego, CA, operated by Doctors Brenda and Mark Wiederhold.  The Virtual Reality Medical Center in San Diego, CA uses a variety of 3D environments to treat phobias.  Thus, environments are tailored to combat fears of  flying, driving, heights, crowds, and public speaking.  The OnLive! Traveler application has been successfully used to foster better communication skills among clients with social phobias.  Shannon McGehee, a doctoral candidate in psychology, introduced the use of Traveler to treat clients with social phobias in 1998, and since then it has afforded them an interesting area of study.

Possible Scenarios for Treatment
Three possible scenarios exist for using Traveler with clients afflicted with social phobia:

1. The therapist guides the client through the Traveler application, allowing them to encounter random individuals in the guise of avatars, just as one would in real life.  The situation is initially uncomfortable for just about any individual, trying to get used to this new paradigm of communication.  But with the therapist present, the client can work through this discomfort.

2. Another therapist incarnates as an avatar in an adjacent room.  This affords a controlled environment, where the other therapist attempts to engage the client in conversation for up to 20 minutes.

3. Users can go into a locked room (rooms can be password protected) and initiate group therapy, for a controlled, supportive environment.  So far, the researchers at VRMC have not facilitated this scenario.

Advantages of Using Virtual Environments
It is important to mention that VR will not cure social phobia, but can be used to augment existing therapies. Social Phobia is difficult to treat because unlike other phobias, such as a fear of flying, social phobia is usually accompanied by a cluster of other personality deficits.  Social phobics often have poor life skills in general; the ability to dress appropriately, to maintain proper hygiene, or to understand personal boundaries may elude them.  For this reason, it is difficult to treat social phobia in just a few short sessions, with or without a virtual reality application.

However, VR offers an important advantage.  Before the use of VR, social phobia had to be treated either through the use of the client’s imagination – envisioning stressful scenarios and their positive conclusions, or through real-life experiences.  There was no intermediate step.  However, Virtual Reality Exposure Therapy, the exposure to the various stimuli related to a client’s phobia, offers that intermediate step.  In a virtual environment, users do not incur the same physical risks as they do in real life; yet the perceived emotional risks are high, evidenced by the clients’ levels of anxiety, which can be quantified by physiological or biofeedback techniques.  Also, in a virtual environment, clients can engage with others under the guise of anonymity while reassured by a trained therapist.  Throughout the encounter, the therapist can suggest coping strategies while encouraging the client to practice diaphragmatic breathing techniques.  But, if the situation suddenly becomes too threatening, the client can simply log off.

Virtual Reality Immersion Therapy
To treat social phobia, the researchers at VRMC may take the client through several steps, or stages that expose him to increasingly higher levels of stimuli, depending on the client’s comfort level:

Pre-Exposure – Controlling Anxiety with Physiological Feedback and Monitoring Devices
Before the client is subjected to the virtual environment, he is first given skills to help him cope with the anticipated stress.  This is accomplished through the use of biofeedback mechanisms.  The client is taught diaphragmatic breathing while hooked up to various biofeedback devices that measure heart rate (EKG), rate of respiration, muscle tension, and galvanic response - skin temperature and conductance influenced by sweat glands; with skin conductance and heart rate variability seen as the most accurate gauge of one’s anxiety level.  These devices offer a quantifiable means of measuring a patient’s level of stress, which would be difficult to ascertain by means of the patient’s subjective interpretation alone.  And by offering visual feedback, the client can objectively observe a decrease in his own respiration and heart rate resulting from proper relaxation techniques.

The First Level of Exposure – 2D images
Immersion in a 3D virtual environment may initially be too threatening for some patients.  The first step then would be to subject the client to an environment inhabited by 2D photographic cut-outs of other humans, superimposed onto a photographic panorama, usually captured by a video camera.  The environment may incorporate ambient sounds, but at VRMC the 2D people themselves do not talk.  The therapist may role-play the voices of the photo images.

The Second Level of Exposure – using OnLive! Traveler in a controlled manner
The client’s initial encounter with Traveler can be both uncomfortable yet fascinating.  A user may initially be so enamored of the 3D spaces, or of his own fantasy likeness, that compelling conversations with others is unlikely.  During this controlled introductory phase, a client may be encouraged to interact with an assisting therapist, appearing in the guise of avatar while logged in from an adjacent room.

The Third Level of Exposure – risk-taking in virtual reality
In this stage, the therapist will accompany the client into one of the more inhabited 3D chat rooms, allowing the client to spontaneously interact with other avatars.  This stage is invaluable, because it offers the anonymity of a virtual space while mirroring the complexities of real-life interaction.  Clients learn that they must engage with others in a friendly manner, else they may be muted with the Ignore button; or at best, others will simply drift away in a gesture of tacit rejection.

Also avatars in this 3D world have a strong sense of boundaries, or personal space.  Each avatar has its own bounding box, or area of influence.  A violation of that boundary will produce an annoying clonking sound.  By repeatedly ramming into another avatar, you can actually push an avatar into a teleportation device, catapulting him into another 3D realm.  Except in the context of a structured game, other users find this practice highly annoying.  In the context of communication, avatars can often be seen in chat rings, groups of evenly spaced entities, who become perturbed if a newcomer suddenly violates this symmetry without being offered a spot in the ring.  Clients with social phobia are forced to recognize this social dynamic, which has its counterpart in the real world as well.

The Fourth Stage – Net Meeting
Net Meeting is a popular tool from Microsoft, used to conduct video conferences, using a microphone and an optional small inexpensive video camera that sits atop a monitor.  This tool works best when both participants have a high-speed connection. Usually the client will converse with another therapist who is in an adjacent room. No longer hidden behind the guise of anonymity, clients must now face the frightening voice and visage of another human being.

The Final Stage – Real-life encounters
Ultimately the goal of this immersion therapy is to catapult the client into the exciting realm of everyday life.  However, usually along the way, throughout the duration of the client’s treatment, the therapist will proscribe homework assignments, which may be as banal as “This week you will ask a waiter for a glass of water.”  Thus, the use of VR can prepare the client for real-life interactions, while providing an intermediate step towards that goal, augmenting more traditional therapeutic techniques.

Anecdotes and Suggestions
 

• Users with social phobia seem to prefer the animal avatars.  Not only do they choose them, they seem more comfortable talking to them.

 
• A poor understanding of personal space often translates into the virtual realm, with clients bumping into other avatars.  This produces an annoying clonking sound, which irritates other users.

 
• One user reportedly needed the constant reassurance that the other avatars were really present, his anxiety propelling him into an incessant feedback loop, chanting, “Can you hear me now! Can you hear me now!”

 
• During the third level of exposure, the therapist takes the client to the room most inhabited by other users.  If one were to design spaces specifically for this clientele, it was suggested that quiet, calm spaces (such as Moon Harbor) with unobtrusive ambient sounds would be preferable.

 
• Clients with social phobia not only fear public situations, but they fear having their discomfort recognized by others.  Thus, if biofeedback devices could cause one's avatar to change colors, in a final stage of treatment, the client could learn to cope with the fact that his discomfort may be recognized by others.

 
• Other Traveler spaces, such as Condor Summit, might be appropriate for clients with acrophobia, or fear of heights.

 
• One user reportedly navigated through the virtual environments with the camera pointed inward (using Ctrl+I), so that he was only viewing himself, framed within the virtual environment.  This gave the therapist an opportunity to discuss why such a strategy may preclude the successful interaction with others.
  
  

This URL illustrates some of the facilities available to the client in a VR clinic.
http://www.vrphobia.com/experience.html

This URL shows images of the medical equipment used to monitor a client’s heart rate.
http://www.vrphobia.com/equipment.html

This URL shows other clinics world-wide who are using VR for therapeutic uses.
http://www.vrphobia.com/associates.html