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VR and PTSD: Healing from trauma by confronting fears in virtual reality environments

By Katie Givens Kime

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What are the ethical implications of therapeutically re-exposing patients to trauma via virtual reality technologies? Of the 2.7 million American veterans of the Iraq and Afghanistan wars, at least 20% suffer from depression and/or post-traumatic stress disorder (PTSD), and other studies peg that percentage even higher. As a chronic, debilitating mental illness, one PTSD symptom is hyperarousal, in which a person repeatedly re-experiences a trauma in the form of nightmares, panic attacks, and flashbacks.  One of the most long-trusted therapeutic approaches to PTSD is exposure therapy; now, virtual reality technology is increasingly being used to simulate exposure to traumatic events and to environments related to the traumatic event.

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Last month’s Neuroethics and Neuroscience in the News event featured the recent research and observations of Barbara O. Rothbaum, who is the Paul A. Janssen Chair in Neuropsychopharmacology at the Emory University School of Medicine and Director of the Emory Veterans Program & Trauma and Anxiety Recovery Program. Rothbaum outlined the way in which exposure therapy (with or without the aid of virtual reality technology) is based on principles of learning and also discussed reliable findings with animals and phobic disorders (Foa & Kozak, 1986). The underlying premise of such therapy is that repeated and prolonged exposure to feared but realistically safe stimuli leads to habituation, and eventually to extinction.

The virtual reality exposure therapy (VRE) combat environments for “Virtual Vietnam” (developed by Georgia Tech and Emory Universities) includes a virtual Huey helicopter, a “fly” over the jungles of Vietnam, a “walk” in clearings near jungles and swamps, and other imaginal immersions in Vietnam-related stimuli. Other examples of VRE environments include “World Trade Center” (Weill Cornell Medical Center/University of Washington), “Terrorist Bus Bombing” (University of Haifa/University of Washington), “Motor Vehicle Accidents” (University of Buffalo), “Virtual Angola” (University of Lusófona de Humanidades e Tecnologias, Lisbon), and “Virtual Iraq” (USC Institute for Creative Technologies).

In some ways, VRE is an enormous innovation, particularly for treatment under a range of conditions not easily controlled or facilitated in the real world. For veterans with extreme anxiety due to in-flight combat events, for example, exposure to flight (including turbulence) is therapeutically valuable. With the help of VRE, recreating that exposure within the context of a 50-minute session in a therapist’s office is immensely more feasible than gaining access to a flight, with an appropriate amount of turbulence. Not only can VRE create dynamic, three-dimensional stimulus environments, it also allows for the recording of behavioral and physiological responses of the patient, which provides clinical assessment options previously unavailable.

While such innovations hold great potential, there are other ways in which VRE is simply an additional tool to aid in traditional exposure therapy, which remains based within the relationship between the clinician and the patient. In her talk, Rothbaum noted that many of the objections and concerns raised about VRE (detailed in an Ethical Issues in Clinical Neuropsychology article by Rothbaum and her colleagues) are similar to concerns raised about exposure therapy in general. Many people (including many clinicians) flinch at the idea of intentionally raising a patient’s anxiety. A primary motivation of any therapist is helping a patient feel better. Thus, exposure therapy can feel counterintuitive because it forces patients to re-experience their trauma and all of the emotions associated with that trauma.

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Other ethical concerns about VRE include the potential for VR-related side effects like cyber-sickness (a form of motion sickness commonly reported with virtual reality technology), and other possible symptoms including disturbed locomotion, changes in postural control, perceptual-motor disturbances, fatigue, and generally lowered arousal. Rothbaum named several mitigating practices employed to limit such symptoms, such as limiting session time, keeping the room cool, using equipment with better resolution, and limiting head motion.

Concerns about misuse of VRE equipment by both clinicians and sufferers of PTSD also emerge. What if clinicians lacking training or expertise use VRE with patients? Or, what if clinicians, no matter how well trained, use VRE at the expense of the normal therapist/client relationship? Rothbaum noted the potentially problematic dynamic of how patients wearing head mounted displays cannot see their therapist, and therefore lose any nonverbal communication that would otherwise be absorbed visually. However, in standard imaginal exposure, patients’ eyes are closed, thus also limiting nonverbal communication. In terms of auditory information, the often loud virtual environments, such as Virtual Iraq or even the virtual airplane, can prevent the patient from hearing the therapist. Furthermore, VRE might allow an interpersonally awkward patient to “hide” behind the technology instead of interacting with the therapist.

In response to the potential for clinical misuse of VRE equipment and techniques, Rothbaum pointed out that “bad VRE therapy is just bad therapy.” While the creators of VRE clinical practices and associated equipment cannot prevent misuse, they can take steps to require appropriate training in as much as possible. As for the therapist-patient interpersonal communications, the VRE equipment includes a microphone that allows the therapist to talk directly with the patient and also privileges the therapist’s voice over the sounds of the virtual environment. A sort of “riding shotgun” intimacy is thus often achieved. Rothbaum also noted that the masking “barrier” of the VR headgear can facilitate more verbalization from patients instead of less, and mimics the therapeutic practice of having patients close their eyes when recounting particular events or feelings or sharing about particular emotional states and in standard imaginal exposure.

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There are still more concerns of VRE misuse. Might continued access to virtual environments like “Virtual Vietnam” lead to cases of faulty self-diagnosis and self-treatment? When individuals are able to download or purchase VRE assessment and therapeutic tools, what might be the associated risks? A major concern is that of desensitization: by taking the opportunity to repeatedly immerse one’s self in violent and otherwise traumatic events, might VRE tools be encouraging desensitization? Rothbaum noted that 70% of us, statistically, will experience a traumatic event in our lifetime, but only a small percentage of us will develop PTSD. Rothbaum used the example of video games as one of myriad tools and methods engaged by those suffering with PTSD, with wide-ranging results. In the end, Rothbaum’s response to these concerns was, “We’re not trying to make realistically scary things less scary…We’re trying to help people cope better with something scary that happened in their past.”

Looking into the future of how virtual reality technology might change the landscape and potential of mental health care, a recent review of all studies employing VR for mental health conditions found many gaps in meaningful applications of the technology. However, on the basis that “Mental health problems are inseparable from the environment,” the reviewers concluded that the greatest potential for VR lies in its ability to take patient and caregiver to the particular contexts in which the patient struggles to respond appropriately.

Even more broadly, some VR innovators are finding some success in creating VR headsets that operate solely via the brain activity of the user. While using dry electrodes to record brain activity via electroencephalography (EEG) is not new, creating a modality that allows for the execution of virtual tasks just as efficiently as physical input devices (keyboard, touch screen, etc.) would be a new achievement. Such an advance might lead to an entirely different range of options and questions when considering how VR technology best serves the purposes of mental health care.

With VR, we can expect significant leaps forward in broadening access and modalities for those seeking care for their PTSD. 


Foa, E.B., & Kozak, M.J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20-35.

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Kime, K.G. (2017). VR and PTSD: Healing from trauma by confronting fears in virtual reality environments. The Neuroethics Blog. Retrieved on , from


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