When psychologist Ralph Lamson first put on a virtual-reality helmet at an exhibition of new technology in San Jose two years ago, he unexpectedly collided with his worst fear: his terror of heights.
He found himself in a tall building looking through floor-to-ceiling windows at a panorama far below. But instead of ripping off the helmet that displayed the illusion, he took a deep breath and began inching toward the windows, reminding himself with each baby step that he was safe--and that what he was experiencing was not real.
Lamson says he walked out of the exhibit hall cured of acrophobia and thinking to himself: "I'd better research this."
Last year--with hardware and software on loan from Division Inc. of Redwood City--Lamson conducted what is believed to be the first, and perhaps only, clinical trial of virtual reality in any health-care field. Lamson, a psychologist at Kaiser-Permanente Medical Group in San Rafael, used the new technology in an attempt to relieve the fears of 36 people who had a 20- to 30-year history of acrophobia.
After just one 50-minute treatment, 90% of the participants were able to complete self-assigned goals such as walking across a bridge or riding a glass-enclosed elevator, he told 700 health-care professionals who recently attended the "Medicine Meets Virtual Reality" conference in San Diego.
"It's clear that the time has come for this technology to be applied for therapeutic use," said psychiatrist Hans Sieburg, director of the Laboratory for Biological Informatics and Theoretical Medicine at UC San Diego.
"But we're still very much at the beginning. We need to know what the brain is doing, if virtual reality changes its neurophysiology. Will it help people or will it fry their brains?"
The other members of a panel of psychiatrists and psychologists who listened eagerly to Lamson's presentation raised more questions:
What other phobias or emotional illnesses could virtual reality be used for? What syndromes would the technology aggravate? What people might be harmed by immersing themselves in a world that isn't real? Is it an advisable treatment for children? With current systems such as the one Lamson used costing between $50,000 and $90,000, will virtual-reality therapy ever be economical?
There were no answers because the technology is too new. (The only voices of concern, so far, are those urging caution.) Lamson, however, is already preparing to expand the clinical trials. "I think it can be used for a range of anxiety disorders," he said, "from public speaking to obsessive-compulsive behavior."
For Marianne Descalzo, who suffered from acrophobia for 46 years, there were no drawbacks. "It's wonderful," she said. "It's a big breakthrough."
A native of San Francisco who now lives in nearby San Rafael, she never walked across the Golden Gate bridge until a few months ago. "Before I did virtual-reality therapy, I visited the Grand Canyon twice and never saw it."
Descalzo was one of 88 people who volunteered for Lamson's study. Forty-four people were randomly assigned to virtual-reality treatment; eight dropped out before receiving the treatment. The others were randomly assigned to one of two traditional treatments--medication or six to 10 cognitive therapy sessions--or placed on a waiting list that provided no treatment, in effect forming the control group.
The virtual-reality treatment consisted of one 50-minute session in which the volunteers wore a virtual-reality helmet for 30 minutes, and two 30-minute follow-up evaluation sessions. The helmet covers the eyes and peripheral vision to block out the real world and contains a small computer screen that displays a computer-graphics environment. The volunteers moved through it by pressing a button on a hand-held grip. Lamson monitored their progress on a small computer screen.
"When they put the helmet on, they're in a cafe," said Lamson. "They see colorful booths and lighting on the walls on one side of the cafe. They turn their head, and see a counter. At one end of the room is a door."
Through the door a plank extends from a patio toward a bridge, but doesn't join it. The bridge resembles the Golden Gate Bridge without railings. Beyond the bridge are mountains; below, water.
"Some people don't want to go out the door at all," said Lamson. "When they do, they wobble, spread their arms for balance, shake, or cry," all while standing in the middle of his office. Some thought the plank was 10 feet above the ground; others perceived it as high as 10 stories.
Lamson monitored their heart rate and blood pressure and talked to his clients as they inched their way across the plank, looked down the side of the patio to the ground, stepped timidly across the gap onto the bridge and looked over the edge to the water. He encouraged them, helped them become aware of their breathing and muscle tension, and guided them to the next part of the virtual environment once they became comfortable in the place they were standing.
Within one week after the treatment, 33 people had completed a self-assigned goal by walking across the Golden Gate Bridge, climbing a ladder, going up a glass-enclosed elevator, said Lamson. Three months later, they accomplished a final task: a ride up and down 15 floors in a glass elevator while looking outside. (The people who did not respond to the therapy were on two ends of a Bell curve, said Lamson: "For some it was too real, for others not real enough.")
Although comparison with the control group and those given the conventional treatments will not be completed for several weeks, Lamson is already planning to take his virtual-reality therapy for acrophobia to other Kaiser hospitals in California, and is hoping to include software that provides treatment for claustrophobia and agoraphobia.
Descalzo says she volunteered for the study because she wanted to clean out her own roof gutters instead of paying someone else to do it.
"When I was 5 years old, I climbed some stairs and crawled out on a ledge and just froze," she said. "Whenever I climbed a tree or anything, I just froze. Now I never get that gripping fear. I've climbed on my roof. I've climbed Mt. Tamalpais. I've been in a 60-foot Ferris wheel. No problem."
In all the volunteers whose fears decreased, Lamson found that their heart rate and blood pressure, which were often significantly elevated when they stepped on the virtual plank, dropped by the time they had reached the end of the bridge and turned around to head back to the cafe. But no one can tell what went on in their brains.
Before virtual-reality therapy becomes commonplace, "we need criteria for effectiveness and reliability in its use," said Sieburg, who plans to develop a therapist-monitored group virtual-reality therapy to be distributed over the Internet.
"Blood pressure, heart rate, EEG and EKG, and comparative behavioral studies are necessary. We need to know what happens to people's perceptions of reality when they use VR three or four hours a day."
Research is important to set standards for virtual-reality therapy, said Jay Otero, a psychiatrist at UC San Diego. "I would have a problem using it with psychotic patients or those who have trouble discerning what is real and not real. A controversial issue is likely to arise with children."
Drexel University neurophysiologist John Hestenes, who directs the Biomedical Engineering and Science Institute at the Philadelphia university, recommended developing physiological indicators to detect the transition from a healthy emotional state to a psychotic one, so that VR use can be carefully monitored. "We do not understand the steps to becoming immersed or feeling a presence in a virtual environment," he said. "I would like to know what they are."
Lamson sees virtual-reality therapy extending beyond anxiety disorders to giving people with depression virtual environments that provide positive images. He thinks it can help children with attention-deficit disorders or individuals who have problems with anger or aggression.
"One of my intentions is to make this very accessible to people," said Lamson. "I think it will cause a lot of people in my profession to re-evaluate what we think we know about people. I think that we can get over things like phobias much faster."