Harnessing the power of conversations with virtual humans to change health behaviors

Effectiveness of a virtual patient simulation training on improving provider engagement in suicide safer care

BACKGROUND

Health care providers have a critical opportunity to mitigate the public health problem of suicide. Virtual patient simulations (VPS) allow providers to learn and practice evidence-based suicide prevention practices in a realistic and risk-free environment. The purpose of this study was to test whether receiving VPS training increases the likelihood that providers will engage in effective suicide safer care practices.

METHODS

Behavioral health and non-behavioral health providers (N = 19) at a Federally Qualified Health Center who work with patients at risk for suicide received the VPS training on risk assessment, safety planning, and motivation to engage in treatment. Providers' electronic health records were compared 6 months pre- and post-VPS training on their engagement in suicide safer care practices of screening, assessment, safety planning, and adding suicide ideation to the problem list.

RESULTS

Most behavioral health providers were already engaging in evidence-based suicide prevention care prior to the VPS training. Findings demonstrated the VPS training may impact the likelihood that non-behavioral health providers engage in suicide safer care practices.

CONCLUSION

VPS training in evidence-based suicide prevention practices can optimize and elevate all health care providers' skills in suicide care regardless of role and responsibility, demonstrating the potential to directly impact patient outcomes.

Talk with Ted: an embodied conversational agent for caregivers

Communication is key to the success of any relationship. When it comes to caregivers, having a conversation with a person living with some form of cognitive impairment, such as dementia, can be a struggle. Most people living with dementia experience some form of communication impairment that reduces their ability to express their needs. In this case study, we present the design of an embodied conversation agent (ECA), Ted, designed to educate caregivers about the importance of good communication principles when engaging with people living with dementia. This training tool was trialed and compared to an online training tool, with 23 caregivers divided into two cohorts (12 in the ECA condition, and 11 in the online training tool condition), over a period of 8 weeks using a mixed evaluation approach. Our findings suggest that (a) caregivers developed an emotional connection with the ECA and retained the learning from their interactions with Ted even after 8 weeks had elapsed, (b) caregivers implemented the learnings in their practice, and (c) the changes in care practice were well received by people living with dementia.

Democratizing the Development of Chatbots to Improve Public Health: Feasibility Study of COVID-19 Misinformation

BACKGROUND

Chatbots enable users to have humanlike conversations on various topics and can vary widely in complexity and functionality. An area of research priority in chatbots is democratizing chatbots to all, removing barriers to entry, such as financial ones, to help make chatbots a possibility for the wider global population to improve access to information, help reduce the digital divide between nations, and improve areas of public good (eg, health communication). Chatbots in this space may help create the potential for improved health outcomes, potentially alleviating some of the burdens on health care providers and systems to be the sole voices of outreach to public health.

OBJECTIVE

This study explored the feasibility of developing a chatbot using approaches that are accessible in low- and middle-resource settings, such as using technology that is low cost, can be developed by nonprogrammers, and can be deployed over social media platforms to reach the broadest-possible audience without the need for a specialized technical team.

METHODS

This study is presented in 2 parts. First, we detailed the design and development of a chatbot, VWise, including the resources used and development considerations for the conversational model. Next, we conducted a case study of 33 participants who engaged in a pilot with our chatbot. We explored the following 3 research questions: (1) Is it feasible to develop and implement a chatbot addressing a public health issue with only minimal resources? (2) What is the participants' experience with using the chatbot? (3) What kinds of measures of engagement are observed from using the chatbot?

RESULTS

A high level of engagement with the chatbot was demonstrated by the large number of participants who stayed with the conversation to its natural end (n=17, 52%), requested to see the free online resource, selected to view all information about a given concern, and returned to have a dialogue about a second concern (n=12, 36%).

CONCLUSIONS

This study explored the feasibility of and the design and development considerations for a chatbot, VWise. Our early findings from this initial pilot suggest that developing a functioning and low-cost chatbot is feasible, even in low-resource environments. Our results show that low-resource environments can enter the health communication chatbot space using readily available human and technical resources. However, despite these early indicators, many limitations exist in this study and further work with a larger sample size and greater diversity of participants is needed. This study represents early work on a chatbot in its virtual infancy. We hope this study will help provide those who feel chatbot access may be out of reach with a useful guide to enter this space, enabling more democratized access to chatbots for all.

Postvention as Prevention: Coping with Loss at School

Many Pre-K through grade 12 (PK-12) students have experienced traumatic events throughout the pandemic in a myriad of ways including the death of family members and peers, loss of social interaction and increased violence at home. The consequences can be traumatic and manifest themselves in fear, anxiety, anger, isolation, and loneliness. Too often this leads to depression, anxiety, grief, substance use disorders, post-traumatic stress disorder, suicidal ideation and even suicides. This study assesses the impact of an innovative virtual human role-play simulation that prepares PK-12 educators, administrators, and school staff to respond to a student death in the school community by creating communities of support to help manage traumatic loss. The simulation addresses crisis response planning, postvention plans, and provides learners with role-play practice in using evidence-based motivational interviewing communication strategies in conversations with students and colleagues after the occurrence of a death. The sample consisted of educators and staff who were recruited from geographically dispersed areas across the US between January 2021 through December 2021. Matched sample t-tests and ANOVAs were used to assess quantitative data, and a qualitative analysis software, MAXQDA, was used to assess open-ended response data. Results show statistically significant increases in school personnel's preparedness and self-efficacy to recognize signs of trauma in their students and colleagues, and to approach them to talk about concerns and, if necessary, make a referral to support services. Simulations such as this hold tremendous potential in teaching educators how address trauma due to a student death.

Compassionate Technology: A Systematic Scoping Review of Compassion as Foundation for Blended and Digital Mental Health Interventions (Preprint)

BACKGROUND

An essential value in mental health care is compassion: awareness of suffering, tolerating difficult feelings in the face of suffering, and acting or being motivated to alleviate suffering. Currently, technologies for mental health care are on the rise and could offer several advantages, such as more options for self-management by clients and more accessible and economically viable care. However, digital mental health interventions (DMHIs) have not been widely implemented in daily practice. Developing and evaluating DMHIs around important mental health care values, such as compassion, could be key for a better integration of technology in the mental health care context.

OBJECTIVE

This systematic scoping review explored the literature for previous instances where technology for mental health care has been linked to compassion or empathy to investigate how DMHIs can support compassion in mental health care.

METHODS

Searches were conducted in the PsycINFO, PubMed, Scopus, and Web of Science databases, and screening by 2 reviewers resulted in 33 included articles. From these articles, we extracted the following data: technology types, goals, target groups, and roles of the technologies in the intervention; study designs; outcome measures; and the extent to which the technologies met a 5-step proposed definition of compassion.

RESULTS

We found 3 main ways in which technology can contribute to compassion in mental health care: by showing compassion to people, by enhancing self-compassion in people, or by facilitating compassion between people. However, none of the included technologies met all 5 elements of compassion nor were they evaluated in terms of compassion.

CONCLUSIONS

We discuss the potential of compassionate technology, its challenges, and the need to evaluate technology for mental health care on compassion. Our findings could contribute to the development of compassionate technology, in which elements of compassion are explicitly embedded in its design, use, and evaluation.

Mental health stigma among college students: Test of an interactive online intervention

Objective: Young adults have low rates of help-seeking despite high rates of mental health problems, which relate to stigmatizing attitudes. Education as well as contact with people with mental health problems may improve stigmatization. The present pilot study tested the efficacy of an online interactive educational intervention that utilizes avatars depicting distressed individuals on stigmatizing attitudes toward mental illness and help-seeking. Participants and Methods: Eighty-five college student participants were assessed on self- and public-stigma as well as attitudes toward help-seeking and were randomly assigned to one of three conditions (intervention, control, post-test only). Results: Pre-post comparisons indicate that interactive programs may be an accessible and efficient means to reduce stigmatizing attitudes toward help-seeking among college students. Future studies should include follow-up assessments and measures of behavior and should consider individual differences. including personal mental health history.

Effectiveness of a minimal virtual motivational interviewing training for first years medical students: differentiating between pre-test and then-test

BACKGROUND

Shifting towards patient-centeredness, medical doctors need patient-centered communication skills. Motivational Interviewing (MI) is an evidence-based, collaborative, goal-oriented communication technique to strengthen a person's own motivation and commitment to change. The purpose of this study is to evaluate the effectiveness of a brief virtual role-play MI-training program on MI-knowledge and skills in first-year undergraduate medical students, making use of both a pre-test and a then-test (retrospective pre-test) to check for response shift in evaluating the educational intervention.

METHODS

Four 10-15 min MI-game-based training conversations embedded in the Kognito Conversation Platform™ were offered to the students using a single-group Interrupted Time Series design.

RESULTS

Participants included 339 undergraduate medical students (RR= 83.1%). The one-hour MI virtual training proved effective in two ways: participants gained knowledge and skills, and increased awareness of the existing intrinsic knowledge and skill they already possess to communicate with future patients in a patient-centered way.

CONCLUSION

A brief one-hour MI-training simulation can be effective even if offered at an early stage during medical education. Furthermore, response shift varied and was not present in all students.

PRACTICE IMPLICATION

The addition of a then-test to the study design reveals results that otherwise would not have been found.

Technology-Based Methods for Training Counseling Skills in Behavioral Health: a Scoping Review

In the present review, we consider technology-based methods for training and monitoring counseling skills in behavioral health (i.e., addictions, mental health, and behavioral medicine). We provide an overview of topical foci and design features, as well as review the available research. The Arksey and O’Malley framework for scoping review was used and there were two project phases. First, we reviewed and charted design features and training topics. Second, we reviewed and charted published research evaluating training outcomes. The search process yielded six commercial companies or academic research centers targeting online training of behavioral health counseling skills. These programs could be categorized by an avatar (i.e., computer-generated) or video (i.e., human actor) client interface, as well as by a completely interactive experience (i.e., virtual reality) or an experience with a pre-programmed, branch-logic interaction (i.e., computer simulation). One final company provided monitoring services only, without an explicit training component. The literature in this area is in its nascent stages, with primarily pilot scope and comparatively less progress if contrasted with fields such as general medicine. Online training and monitoring of behavioral health counseling skills is a promising emerging field with positive qualities such as scalability, resource efficiency, and standardization. Future research should emphasize (1) between-group randomized clinical trials, (2) comparisons to standard training practices, and (3) alignment with professional competency standards.

From Digital Health to Digital Well-being: Systematic Scoping Review

Background

Digital health refers to the proper use of technology for improving the health and well-being of people and enhancing the care of patients through the intelligent processing of clinical and genetic data. Despite increasing interest in well-being in both health care and technology, there is no clear understanding of what constitutes well-being, which leads to uncertainty in how to create well-being through digital health. In an effort to clarify this uncertainty, Brey developed a framework to define problems in technology for well-being using the following four categories: epistemological problem, scope problem, specification problem, and aggregation problem.

Objective

This systematic scoping review aims to gain insights into how to define and address well-being in digital health.

Methods

We followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. Papers were identified from 6 databases and included if they addressed the design or evaluation of digital health and reported the enhancement of patient well-being as their purpose. These papers were divided into design and evaluation papers. We studied how the 4 problems in technology for well-being are considered per paper.

Results

A total of 117 studies were eligible for analysis (n=46, 39.3% design papers and n=71, 60.7% evaluation papers). For the epistemological problem, the thematic analysis resulted in various definitions of well-being, which were grouped into the following seven values: healthy body, functional me, healthy mind, happy me, social me, self-managing me, and external conditions. Design papers mostly considered well-being as healthy body and self-managing me, whereas evaluation papers considered the values of healthy mind and happy me. Users were rarely involved in defining well-being. For the scope problem, patients with chronic care needs were commonly considered as the main users. Design papers also regularly involved other users, such as caregivers and relatives. These users were often not involved in evaluation papers. For the specification problem, most design and evaluation papers focused on the provision of care support through a digital platform. Design papers used numerous design methods, whereas evaluation papers mostly considered pre-post measurements and randomized controlled trials. For the aggregation problem, value conflicts were rarely described.

Conclusions

Current practice has found pragmatic ways of circumventing or dealing with the problems of digital health for well-being. Major differences exist between the design and evaluation of digital health, particularly regarding their conceptualization of well-being and the types of users studied. In addition, we found that current methodologies for designing and evaluating digital health can be improved. For optimal digital health for well-being, multidisciplinary collaborations that move beyond the common dichotomy of design and evaluation are needed.

Intelligent Cognitive Assistants for Attitude and Behavior Change Support in Mental Health: State-of-the-Art Technical Review

Intelligent cognitive assistant (ICA) technology is used in various domains to emulate human behavior expressed through synchronous communication, especially written conversation. Due to their ability to use individually tailored natural language, they present a powerful vessel to support attitude and behavior change. Behavior change support systems are emerging as a crucial tool in digital mental health services, and ICAs exceed in effective support, especially for stress, anxiety and depression (SAD), where ICAs guide people’s thought processes and actions by analyzing their affective and cognitive phenomena. Currently, there is no comprehensive review of such ICAs from a technical standpoint, and existing work is conducted exclusively from a psychological or medical perspective. This technical state-of-the-art review tried to discern and systematize current technological approaches and trends as well as detail the highly interdisciplinary landscape of intersections between ICAs, attitude and behavior change, and mental health, focusing on text-based ICAs for SAD. Ten papers with systems, fitting our criteria, were selected. The systems varied significantly in their approaches, with the most successful opting for comprehensive user models, classification-based assessment, personalized intervention, and dialogue tree conversational models.

Innovative Virtual Role Play Simulations for Managing Substance Use Conversations: Pilot Study Results and Relevance During and After COVID-19

BACKGROUND

Substance use places a substantial burden on our communities, both economically and socially. In light of COVID-19, it is predicted that as many as 75,000 more people will die from alcohol and other substance use and suicide as a result of isolation, new mental health concerns, and various other stressors related to the pandemic. Public awareness campaigns that aim to destigmatize substance use and help individuals have meaningful conversations with friends, coworkers, or family members to address substance use concerns are a timely and cost-effective means of augmenting existing behavioral health efforts related to substance use. These types of interventions can supplement the work being done by existing public health initiatives.

OBJECTIVE

This pilot study examines the impact of the One Degree: Shift the Influence role play simulation, designed to teach family, friends, and coworkers to effectively manage problem-solving conversations with individuals that they are concerned about regarding substance use.

METHODS

Participants recruited for this mixed methods study completed a presurvey, the simulation, and a postsurvey, and were sent a 6-week follow-up survey. The simulation involves practicing a role play conversation with a virtual human coded with emotions, a memory, and a personality. A virtual coach provides feedback in using evidence-based communication strategies such as motivational interviewing.

RESULTS

A matched sample analysis of variance revealed significant increases at follow-up in composite attitudinal constructs of preparedness (P<.001) and self-efficacy (P=.01), including starting a conversation with someone regarding substance use, avoiding upsetting someone while bringing up concerns, focusing on observable facts, and problem solving. Qualitative data provided further evidence of the simulation's positive impact on the ability to have meaningful conversations about substance use.

CONCLUSIONS

This study provides preliminary evidence that conversation-based simulations like One Degree: Shift the Influence that use role play practice can teach individuals to use evidence-based communication strategies and can cost-effectively reach geographically dispersed populations to support public health initiatives for primary prevention.

The Effect of Multimodal Emotional Expression on Responses to a Digital Human during a Self-Disclosure Conversation: a Computational Analysis of User Language

Digital humans show promise for use in healthcare as virtual therapists to deliver psychotherapy or companions for social support. For digital humans to be effective and engaging in these roles, it is important they can build close relationships with people. Emotional expressiveness can improve social closeness in human relationships, especially for females. However, it is unknown whether multimodal emotional expression improves relationships with digital humans. Participants were 185 adults aged 18 years or older with English fluency. Participants were block-randomized by gender to complete the Relationship Closeness Induction Task with one of six versions of a digital human. The digital humans varied in modality richness (face, no face) and emotional expression (emotional voice, neutral voice; emotional face, neutral face). Participants' language was analysed for emotional content using Linguistic Inquiry and Word Count software. A series of three-way ANOVA and ANCOVA were conducted to evaluate the effect of digital human face type, voice type, and participant gender on emotional content in participant language. A digital human with no face was associated with more first-person singular pronoun use than a neutral face and an emotional face digital human. A digital human with no face and a neutral voice received more general negative emotion language than a digital human with no face and an emotional voice. Findings suggest the presence of a face and emotion in the voice may improve emotional responses to digital humans. Results provide evidence for aspects of the theoretical framework of embodied agent-patient communication.

Educating Ambulatory Care Nurses to Address Substance Use

BACKGROUND

Screening, brief intervention, and referral to treatment (SBIRT) for substance use has an impact on morbidity and mortality and health care cost.

LOCAL PROBLEM

Nurses in ambulatory care settings may lack knowledge about evidence-based substance use SBIRT.

METHODS

A comparison of pre- and postintervention data was performed to determine whether knowledge improved and to identify facilitators and barriers to SBIRT implementation.

INTERVENTIONS

Nurses completed an online self-paced program focusing on alcohol and drug use screening, motivational interviewing used in a brief intervention, and referral to specialty treatment.

RESULTS

Postintervention knowledge scores increased (P < .001). Facilitator and barrier themes included time, education, resources, receptivity, and interprofessional collaboration.

CONCLUSIONS

The implementation of the SBIRT online program was feasible for nurses to complete during work hours and resulted in increased SBIRT-related knowledge.

Nurse-Led Delivery of Brief Interventions for At-Risk Alcohol Use: An Integrative Review

BACKGROUND: Nurses are in key positions to reduce the global burden associated with alcohol, yet many are ill-prepared to screen for alcohol use and intervene accordingly. The purpose of this integrative review was to identify best practices for educating nurses to work with patients who are at risk for alcohol-related adverse consequences, implement alcohol screening, and deliver alcohol brief interventions (ABIs). AIMS: To identify and synthesize findings from randomized control trials of ABIs delivered by nurses to patients identified through screening to be at risk because of alcohol use. METHOD: The results of 11 published randomized control trials identified from a multi-database search were synthesized. RESULTS: The Alcohol Use Disorder Identification Test was used for alcohol screening in more than half of the studies. Most of the ABIs were based on motivational interviewing and delivered in 30 minutes or less. While there was limited information on the characteristics of nurses who delivered the interventions and how nurses were prepared to deliver the ABIs, the exemplar was a full day workshop teaching nurses on an evidence-based framework for the ABI. All studies measured alcohol consumption as an outcome, yet few used rigorous methods for obtaining this self-reported data. CONCLUSIONS: A 1-day workshop is recommended as an educational modality to prepare nurses to implement the Alcohol Use Disorder Identification Test for identification of persons who are at risk because of alcohol use, deliver a structured brief intervention in less than 30 minutes, and utilize a standard measure of alcohol consumption for evaluation.

Using Virtual Reality Exposure Therapy to Enhance Treatment of Anxiety Disorders: Identifying Areas of Clinical Adoption and Potential Obstacles

Despite strong evidence of effectiveness, exposure therapy is an underutilized treatment for anxiety disorders at a time when effective treatment for anxiety is greatly needed. The significant worldwide prevalence and negative impact of anxiety are documented and highlight the importance of increasing therapist and patient use of effective treatment. Obstacles to the use of exposure therapy are explored and steps to lessen these obstacles are proposed. In particular, virtual reality (VR) technology is discussed as a way to increase the availability of exposure therapy. Incorporating VR in therapy can increase the ease, acceptability, and effectiveness of treatment for anxiety. VR exposure therapy (VRET) permits individualized, gradual, controlled, immersive exposure that is easy for therapists to implement and often more acceptable to patients than in vivo or imaginal exposure. VR is presented as a scalable tool that can augment access to and effectiveness of exposure therapy thus improving treatment of anxiety disorders. VR also has the potential to help with assessment and with therapist training standardization. The authors advocate for providing continuing education in VRET to practicing clinicians and including training in exposure therapy and VRET in training programs. Ongoing development of VR applications for clinical use is encouraged, especially when developed in collaboration with software developers, clinical users, therapists who are experienced in VRET, and researchers.

Predictors of Response to Cognitive-Behavioral Therapy for Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is a common and distressing or impairing preoccupation with a perceived defect in physical appearance. Individuals with BDD engage in time-consuming rituals to check, hide, or "fix" their appearance or alleviate distress. BDD is associated with substantial psychosocial impairment and high rates of depression, hospitalization, and suicidality. Cognitive-behavioral therapy (CBT) is the treatment of choice for BDD, but not everyone benefits. We examined predictors of CBT-related improvement, an important topic that has received very limited investigation. Treatment was delivered in weekly individual sessions over 18-22 weeks. Results indicated that greater motivation/readiness to change (University of Rhode Island Change Assessment Questionnaire), greater treatment expectancy (Treatment Credibility/Expectancy Questionnaire), and better baseline BDD-related insight (Brown Assessment of Beliefs Scale) significantly predicted better CBT response at posttreatment. Baseline BDD symptom severity and depression did not predict outcome, suggesting that even patients with more severe BDD and depressive symptoms can benefit from CBT for BDD. Efforts should be aimed at enhancing readiness to change and confidence in the treatment at treatment onset as well as addressing the poor insight that often characterizes BDD.

Suicide risk assessment training using an online virtual patient simulation

BACKGROUND

Improving the identification of and intervention with patients at risk for suicide requires innovative training techniques that safely and effectively teach or enhance practitioners' skills. Virtual patient simulations (VPS) can be particularly effective for this purpose because they allow for repetition in skill building as well as a safe space to practice difficult interactions with patients. The purpose of this study was to assess the feasibility and acceptability of a novel VPS that trains practitioners in suicide risk assessment, as well as to examine pre-post changes in suicide-related knowledge through a pilot of the VPS training.

METHODS

Practitioners (n=20) were recruited from a Federally Qualified Health Center in the northeastern United States to test the feasibility and acceptability of a VPS suicide risk assessment training. A paired samples t-test was conducted to compare mean differences in practitioners' suicide risk assessment knowledge scores from pre- to post-training, on a scale of 0 to 10.

RESULTS

The VPS was feasible to implement, with 18 of 20 participants using the VPS for an average of 21 to 95 minutes, and was acceptable to participants, with an average satisfaction rating of 5.82 out of 7. Participants' knowledge scores improved significantly by an average of 1.86 points from pre- to post-training.

CONCLUSIONS

The VPS was feasible and acceptable to this sample of practitioners and significantly increased knowledge from pre- to post-training. As such, VPS holds promise as a technique to develop skills in suicide risk assessment.

Using Virtual Patient Simulations to Prepare Primary Health Care Professionals to Conduct Substance Use and Mental Health Screening and Brief Intervention

BACKGROUND

Primary health care professionals are in an excellent position to identify, screen, and conduct brief interventions for patients with mental health and substance use disorders. However, discomfort in initiating conversations about behavioral health, time concerns, lack of knowledge about screening tools, and treatment resources are barriers.

OBJECTIVE

This study examines the impact of an online simulation where users practice role-playing with emotionally responsive virtual patients to learn motivational interviewing strategies to better manage screening, brief interventions, and referral conversations.

DESIGN

Baseline data were collected from 227 participants who were then randomly assigned into the treatment or wait-list control groups. Treatment group participants then completed the simulation, postsimulation survey, and 3-month follow-up survey.

RESULTS

Results showed significant increases in knowledge/skill to identify and engage in collaborative decision making with patients.

CONCLUSIONS

Results strongly suggest that role-play simulation experiences can be an effective means of teaching screening and brief intervention.

Embodied Conversational Agents for the Detection and Prevention of Suicidal Behaviour: Current Applications and Open Challenges

Embodied conversational agents (ECAs) are advanced computational interactive interfaces designed with the aim to engage users in the continuous and long-term use of a background application. The advantages and benefits of these agents have been exploited in several e-health systems. One of the medical domains where ECAs are recently applied is to support the detection of symptoms, prevention and treatment of mental health disorders. As ECAs based applications are increasingly used in clinical psychology, and due that one fatal consequence of mental health problems is the commitment of suicide, it is necessary to analyse how current ECAs in this clinical domain support the early detection and prevention of risk situations associated with suicidality. The present work provides and overview of the main features implemented in the ECAs to detect and prevent suicidal behaviours through two scenarios: ECAs acting as virtual counsellors to offer immediate help to individuals in risk; and ECAs acting as virtual patients for learning/training in the identification of suicide behaviours. A literature review was performed to identify relevant studies in this domain during the last decade, describing the main characteristics of the implemented ECAs and how they have been evaluated. A total of six studies were included in the review fulfilling the defined search criteria. Most of the experimental studies indicate promising results, though these types of ECAs are not yet commonly used in routine practice. The identification of some open challenges for the further development of ECAs within this domain is also discussed.

Clinical Virtual Reality tools to advance the prevention, assessment, and treatment of PTSD

Numerous reports indicate that the incidence of posttraumatic stress disorder (PTSD) in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) military personnel has created a significant behavioural healthcare challenge. These findings have served to motivate research on how to better develop and disseminate evidence-based treatments for PTSD. The current article presents the use of Virtual Reality (VR) as a clinical tool to address the assessment, prevention, and treatment of PTSD, based on the VR projects that were evolved at the University of Southern California Institute for Creative Technologies since 2004. A brief discussion of the definition and rationale for the clinical use of VR is followed by a description of a VR application designed for the delivery of prolonged exposure (PE) for treating Service Members (SMs) and Veterans with combat- and sexual assault-related PTSD. The expansion of the virtual treatment simulations of Iraq and Afghanistan for PTSD assessment and prevention is then presented. This is followed by a forward-looking discussion that details early efforts to develop virtual human agent systems that serve the role of virtual patients for training the next generation of clinical providers, as healthcare guides that can be used to support anonymous access to trauma-relevant behavioural healthcare information, and as clinical interviewers capable of automated behaviour analysis of users to infer psychological state. The paper will conclude with a discussion of VR as a tool for breaking down barriers to care in addition to its direct application in assessment and intervention.