Making self-help virtual reality exposure therapy accessible: hardware and design considerations
DOI: http://dx.doi.org/10.17993/3ctecno.2019.specialissue.02
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MAKING SELF-HELP VIRTUAL REALITY EXPOSURE THERAPY
ACCESSIBLE: HARDWARE AND DESIGN CONSIDERATIONS
Muhammad Tahir
Department of Computer Engineering
Sir Syed University of Engineering and Technology, Karachi, (Pakistan)
E-mail:tahirfattani@gmail.com
Rabia Noor Enam
Department of Computer Engineering
Sir Syed University of Engineering and Technology, Karachi, (Pakistan)
E-mail: afaq_rabia@yahoo.com
Najma Ismat
Department of Computer Engineering
Sir Syed University of Engineering and Technology, Karachi, (Pakistan)
E-mail: najma_ismat@yahoo.com
Syeda Fizza
Department of Computer Engineering
Sir Syed University of Engineering and Technology, Karachi, (Pakistan)
E-mail: fizzy.syeda@gmail.com
Making self-help virtual reality exposure therapy accessible: hardware and design considerations
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ABSTRACT
Virtual Reality Exposure therapy has proven to be as effective as cognitive
behavioral therapy with in vivo exposure [1]. Since it is an efficacious and cost
effective alternative to in vivo exposure therapy, it can be offered to the clients via
software packages containing educational material and self- report questionnaires
considering the present state of Virtual Reality technology. This paper aims to
identify design considerations and constraints, knowledge of which is highly useful
in developing the applications that are accessible user-friendly, require minimal or
no therapeutic contact and provide self-help solution to the inaccessibility of anxiety
treatment which leads to a massive number of patients being left untreated.
KEYWORDS
Anxiety, Phobia, Virtual Reality, Exposure Therapy, Vivo Exposure.
1. INTRODUCTION
Anxiety disorder is the most prevalent mental disorder. But the stigma attached to
mental disorders in addition to the unavailability of proper and affordable
treatment leads to it being left untreated. Virtual Reality Exposure Therapy is being
studied for a long period of time and can be considered an effective alternative to
cognitive behavioral therapy [2]. The major barrier in receiving any kind of
treatment is the lack of its accessibility and affordability. According to a psychiatry
journal, people generally seek treatment after 6 to 8 years of suffering from mood
disorders and 9 to 23 years of suffering from anxiety disorders [3]. With the rapid
growth of interest in VR technology, the future of VRET is promising.
As VRET becomes convenient, it will be easier to develop standalone VRET
experiences but it requires consideration of design and hardware. Developing such
virtual environments not only requires understanding of human side of VR but also
the understanding of the specific phobias and disorders the environment is being
designed. This will make VRET applications efficacious, affordable and accessible
which will lead to patients seeking help leading to less delay in initial contact for
treatment and delay in treatment of the disorder.
2. VRET AND ACCESSIBILITY
The common question asked regarding VRET is that why VRET is considered if
the option in vivo exposure therapy is available. In vivo exposure therapy with or
without relaxation is just as effective but VRET is a good alternative if not better for
the following reasons:
VRET allows the user to have more control over the situation [4]. The
application that is designed a way in which the exposure is increased by using
various levels and after taking subjective units of discomfort (SUDs) in
account will less reluctance from patient.
In vivo exposure can be expensive when it comes to exposing patient to
environments that are usually out of reach. For instance, if patient had flight
phobia, in vivo exposure will be costly [5]. There is a high chance of fear
coming back after just one session. This virtually generated environment will
be an aid is this situation or in a similar one.
Refusal to initiate a treatment is a major issue when it comes to in vivo
exposure. According to a survey regarding the acceptability of virtual reality
Making self-help virtual reality exposure therapy accessible: hardware and design considerations
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(VR) exposure, the refusal rate of initiating treatment with in vivo exposure
was greater than VR exposure. Thus it can be concluded that VRET results
in more people seeking therapy [6].
Another major hindrance in seeking help is confidentiality. People like to
keep the information regarding their treatment confidential. According to
an article published in Journal of Health Cognitive Behaviour Therapy 2017
[7], "An ethical advantage of VRET is that you can do “in-vivo”-like
exposures without leaving the office."
3. DESIGNING VIRTUAL ENVIRONMENT FOR THERAPY
For designing virtual environments, many considerations are to be made. Few of
them are listed thoroughly below:
3.1. Hardware
i. Terminology
Head Mounted Display (HMD): A head-mounted display is worn over
head. For VR, stereo binocular HMDs are used which means that two
separate images are rendered, one for each eye. In short it us the
combination of two monocular displays.
Virtual Environment: Virtual environment is anything that is visible
to the user when he puts on head mounted display. Virtual
environment stimulates mind by presenting it visuals and sometimes
makes use of other senses.
Figure 1. Mean and standard error of E
2
I scores [8].
Simulator Sickness: Motion sickness that maybe induced by exposure
to virtual environments due to badly designed experience, too much
movement or prolonged use.
Immersion: Immersion is the measure of presence user feels in the
virtual environment.
Degree of Freedom (DOF): Degree of freedom is the level of
dependency the hardware allows for translation and rotation in the
virtual environment.
Field of View (FOV): It is the space that is visible to user at any given
time in virtual reality. A research verified the relation between
engagement, enjoyment and immersion graph and the field of view
Making self-help virtual reality exposure therapy accessible: hardware and design considerations
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[8]. The results are illustrated in the graph which is shown in figure
[1]:
ii. Past Limitations of Hardware
VRET proved to be efficacious in the past but there were many hardware
limitations present. It is important to specify those limitations to assist in
finding the appropriate HMD for own design.
These limitations are listed below:
Low computational Power: In the past, head mounted displayed had
low computational power which has improved drastically with the
advancement of VR technology.
Low Frame Rates: Maintaining frame rate of over 75 frames per
second is very important for a good virtual reality experience. With
new HMDS, it is now possible to maintain that frame rate. Low frame
rate also cause nausea, bad user experience and distortion of view
which results in breaking of immersion. The inconsistencies in the
motion of simulator and the user cause simulator sickness [9].
Low Resolution: Since in VR, images are not viewed on one single flat
panel screen, instead they are blown up. Low resolution results in
making experience less immersive.
Low Refresh Rate: Refresh rate is another factor that can potentially
contribute to simulator sickness. It is the rate at which the content on
the screen are updated. It is measured in Hertz. It is important to
have a refresh rate of 90 Hz in VR. It is possible to have a refresh rate
of 120 Hz with some of the current HMDs which was difficult to
achieve in the past.
Inaccessibility: HMDs are now available easily at different prices in
the market. This was not the case in the past. It was difficult to find a
VR system and set it up for proper use.
Installation: Installation and setup of VR devices required a lot of
expertise. Now it can all be done with few clicks.
These limitations were stated above in order to describe the parameters
that should be considered when choosing hardware for VRET and they
can be summarized as in Table 1:
Table 1. Summarized Specifications.
1
Frame Rate Per Second (FPS)
>60 fps
2
Refresh Rate
At least 60 Hz
3
Resolution
Varies with HMDs
4
Field of View
Varies with HMDs
iii. Other Considerations
Another important question to ask is whether the platform is a mobile platform or
stationary VR. With 3 DOFs, head rotation is tracked by HMDs which is called
orientation tracking and with 6 DOFs, head rotation with translation and movement
in spaced is tracked which is called positional tracking. The hardware should be
chosen considering all these parameters. This choice depends on the target
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application and environment design. There are few limitations of mobile VR, for
instance, computational power is low, and fewer head-tracking and user input
options are available. Stationary VR systems cost more and allows user to share the
experience. This advantage may help the therapist to get involved in the experience
with the user.
Table 2. A Comparison of VR Platforms for VRET.
Stationary
Mobile
High Cost
Low Cost
Easy
Only through verbal
communication
Possible
Possible
High
Low
Moderately suitable
Highly Suitable
More options available then
mobile VR
Limited
3.2. Personal Presence and Movement
Personal presence is the degree to which a user feels immersed in the virtual
environment where as environmental presence is defined as the extent to which the
environment reacts to the user’s presence. Complex visuals improve the personal
presence is VRET. A research done with regards to public speaking proved that
user reacts more to animated public than to static public [10]. Thus a moving and
interactive object or stimuli will immerse the user more than a static object.
Movements require more computational sources but in the long run it make the
experience more effective. It is also discussed in a research that a realistically moving
but graphically poor object is stimulates a user more than a realistically textured
static object. High end graphics are not requires as long as anxiety provoking factor
of motion is present [11]. Some textures in VR can also be computationally
expensive. Thus, computational resources should be utilized carefully considering
these results.
There is no research present that proves any effect of user movement in the virtual
environments towards the stimuli. But if a virtual environments demands
movement, it should be kept minimal as it may cause motion sickness.
3.3. Sound
Similar to the reality we live in, it is important in VR that sounds come from a proper
source. This does not only help with interactivity but also helps in making sure that
immersion never breaks at any point. It keeps the real world distractions away from
the users. Few design decisions that you have to make regarding sound are:
2D or 3D Audio: 2D sounds are usually used for 2D screens and
applications. If a VR experience has different sound sources, then 3D
audio should be preferred.
Mono or Stereo: Stereo makes a user feel that he is located in a three
dimensional sound source. Mono sounds save disk space but they are
better suited for 2D designs.
Making self-help virtual reality exposure therapy accessible: hardware and design considerations
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Binaural Sounds: 3D sounds can be used to draw a user's attentions. It
is particularly important in a VR experience because user can look in
any direction and the source of sound must make sense to the user.
Sounds in VRET are to be carefully picked. It is proven that stereo sounds are
appropriate for VR experiences. According to a research, people can differentiate
between stereo and mono sounds. This result had a great effect on the developed
environment [12].
Another question that arises is if 3D audio has any relation with the presence in the
environment. The results presented by research state that "significant difference in
spatial perception was found between 3Daudio and stereo or Dolby sound, although
the median score indicated a trend in favor of 3D audio" [12].
For VRET, a good design decision is to avoid using sounds that are not relevant to
the environment and only to use sound that may enhance the experience. If a voice
assistant is to be included, it is better to make sure that it's not adding to anxiety of
the patient which may lead to patient dropping out of therapy.
Good sound decisions enhance the user’s experience during VRET in following
ways:
For VRET, the exposure intensity is predominantly a measure of visuals
cues but sound plays an important role in creating the illusion. For
therapy to be effective, it is important to match audio with the visuals.
If the stimulus is not chiefly visual, appropriate sound setup will increase
efficacy.
Voice assistance is an added advantage for blind and partially sighted
patients [13].
It helps in drawing attention of user to different spots within the scene.
For instance, you may want the user to look down from a glass elevator
for arachnophobia, thus to draw user’s attention to the ground, an
appropriate sound can be used.
If mind-relaxation or other calming sounds are needed at some point in
therapy, they should be played at the right moment for the right amount
of time to avoid the mismatch of simulation and sound.
Attaching 3D sounds to object is a technique that can be used through
rendering engines which leads to all the sound coming from the right
distance from the correct object. As the users distance from the object
increased, the effect of sound decreases [14].
3.4. Degree of Interactivity
Interactivity plays a big role in increasing the presence hence improving the efficacy
of VRET. The extent to which an environment can be made interactive is
dependent on different variables. Some of them were elaborated in a research [15]
and are listed below:
Number of inputs that environment responds to.
The extent to which the environment can be modified by the user.
The extent to which environment alters during the experience.
Ability to realistically interact with objects in virtual environment, for
instance, the ability to hold and throw object with hands rather than click
of a button.
The responsiveness speed when user interacts with the environment.
Making self-help virtual reality exposure therapy accessible: hardware and design considerations
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Increasing the number of inputs will not have any positive effect but interactivity
should be added where it is required.
3.5. User Interface
Designing UI for a VR experience is a rather challenging task. There are all kinds
of options available which will be stated for assistance. But it entirely depends on
how the environment is setup. Design of user interface depends on many factors. A
research summarized the guidelines and preference for therapist led sessions. These
are summarized as [16]:
Therapists should be provided an automated environment.
Provide therapists with the input from the user including SUD scores,
their comments, options they choose and their current status.
Design for error prevention by not allowing therapists to trigger
inappropriate simulation events.
Provide therapists with predefined comment flags to record events in the
session.
In a VRET environment where the position of the patient is fixed in the
VR world, therapists do not need an external viewpoint of the VR world
with a projection.
For self-help applications or minimal therapist contact VRET these design
considerations may still be helpful. In a VR environment, user should be able to
interact easily; user should be able to control the stimuli while being encouraged to
continue the therapy. Another alternative is to use Subjective Units of Distress
(SUDs) to choose the level of exposure which is shown in table [3]. SUDs can be self-
reported and recorded through user input.
Table 3. Subjective Units of Distress Scale.
Score
Intensity of Disturbance
10
Close to a nervous breakdown
9
Losing Control
8
Alienation
7
Maintaining control with difficulty
6
Moderately Uncomfortable
5
Somewhat Uncomfortable
4
Mildly Upset
3
Feeling Unpleasant
2
Bit Bothered
1
No or Minor Distress
0
Total Relief
4. DESIGNING COMPONENTS
4.1. Progression through Levels
In therapist-led applications, therapist is given a scene-control which they can adjust
as they communicate verbally with patients. Some of the controls that patients and
therapist possess are:
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Table 4. Scenario Controls.
Therapist’s Control
Patient’s Control
Check for SUD’s
Input SUDs
Ask for SUD’s Input
Ask therapist for help when feeling
uncomfortable
Ask patient to explain fear
Suggest or go to easier scenario
Ask patient to explain scenario
Suggest or go to harder scenario
Help patient through the experience
through different techniques
Use other software options e.g. volume etc.
Suggest patient to make progress
Quit
The main purpose of these controls is to make progress and gather the courage to
progress to next level which is shown in table [4]. This feature can be implemented
in VR through utilizing the level progression by use of SUDs. Voice assistance or
other techniques can be used to encourage the user to deal with the phobia.
4.2. Rewards and Scores
Serious gaming with scores and rewards can motivate the user to make progress
during VRET. Games are engaging and help user learn naturally. The feature of
gamification should be added keeping the purpose of the therapy in mind.
Gamifications should not create a barrier for the therapeutic effect of the system.
The effectiveness of serious games in the treatment of mental illness was researched
and proven [15]. VR makes it easier to develop serious games for phobia and anxiety
by adding rewards and score to each level. The use of game engines available make
easy translation of ideas possible.
There arises a question of increasing anxiety levels with anxiousness to make
progress but a study has shown that casual games can be developed to reduce stress
and improving mood [17]. Significant changes in anger, mood, confusion and
fatigue were seen by playing the games designed for the study.
Thus gamification is a tool in the VRET development toolbox that should be utilized
for making the experience as effective for patient as possible.
4.3. Psychoeducation
Anxiety and depression are most prevalent disorders thus there are many
approaches to help patient receive the treatment that they are looking for. Psycho-
education intervention during CBT is one of the approaches. Psycho-education
intervention over time can help in reduction of symptoms over time which proves
it efficacy [18].
In VRET, these interventions can be provided to the patient as a separate package
or as assistance during the therapy. Separate learning environment can be
developed for the sake of educating the user. Psychoeducation is not limited to
being aware of the illness or phobia but also includes the self-care solutions,
information regarding stimuli and studies regarding the illness.
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5. CHALLENGES
The self-help applications available in the commercial market are of questionable
quality as they are not subjected to any evaluation. There is no criteria available to
rate those application or their ability to help patients reduce their symptoms. No
user tests or reviews are available to prove their efficacy. It is challenge to determine
what works for self-help VRET and what doesn’t. There are no tests made
considering those applications that could totally assess the working of them. No
subtle standards are being declared that could analyze the quality and efficiency of
these applications and regarding the commercial market it cannot be determined
that to what extent these applications work and there is no quantitative analysis to
figure the percentage of reduction of the symptoms.
Even though with the advancement of technology and abundance of smart-phones,
these applications can be made readily available but in the end, the question of
whether they fulfill the purpose cannot be answered for each and every application.
To develop state of the art next generation self-help VRET application test and trial
method is not enough; all the design considerations few of which were listed in this
paper should be kept in mind before development to get a perfect application that
serves the objectives.
The availability of VR tools is still rare in developing countries like Pakistan, many
people don’t have access to it considering the economical conditions of the people
and the high cost of the tools , According to a research carried out only 17.8% of
the population uses internet, while addressing the factor that VR tools are rather
very costly and are considered a thing only for the rich people it would be very
hard to say if it would gain popularity among countries where the ratio of access
to the internet is quite low because it is supposed to target those people who couldn’t
bear the cost going to a psychiatrist for their anxiety issues and consider it as a taboo
doing that
A highly professional team is required for the designing and development of this
sort of applications. Someone having a proper insight and first degree could come
up with a perfect development strategy that meets all the requirement of the design
and is beneficial in every way for the patients to treat their problems while
remaining in a virtual environment. Anyone developing this type of application
need to perfectly understand all the design constraints and then do a provision of
the most perfect solution to it. The developer is needed to develop such an
environment which is extremely user friendly because as long as the user is
concerned he or she must be totally comfortable with the environment in order to
outmaneuver the obstacles of the anxiety problems.
Coming up with a product that is in every aspect helpful to the user is not useful
that addresses this type of scenario. A number of meaningful meetings are required
between the psychiatrists and the developers so they could ensure the delivery of
the product that surely reduces the symptoms of the issue lingering within the user
.Developers and psychiatrists are needed to indulge themselves in the meaningful
conversations to come up with the required results that serves all the objectives.
6. CONCLUSIONS
Research has proven that VRET is as effective as CBT and the acceptance rate of
VRET is higher in some cases than CBT. Use of these applications should not be
limited therapist’s office and should be made available to the public whenever it is
possible.
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These applications will be very beneficial in a long run if designed with keeping all
the design constraints in mind. Although many design solutions are applicable but
there is a subtle need of coming up with those scenarios that would help the users
to overcome their anxiety challenges completely. They will be useful for the people
who couldn’t afford a therapist; they will be useful for the people who don’t prefer
going to a therapist and many other more benefits.
The main idea is to make them approachable to the laymen, and the provision of
the scenarios that could serve as an all-time solution to the mental problems like
phobias and anxiety without having one to put a diligent work on it. There is still a
need to subject these applications to evaluation to make sure that they are fulfilling
their purpose.
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AUTHORS
Dr. Muhammad Tahir received the BS degree in computer
engineering from Sir Syed University, M.E. degree in Computer
System from NED University and PhD in Information Science
from University of Roma Tor Vergata. He is cur rently Associate
Professor in Sir Syed University of Engineering and Technology,
Karachi. His research interests include IP Switches/Routing,
IPv4 Protocol, Firewall, IoT, Security Cryptography and
Wireless Networks.
Dr. Rabia N. Enam received her PhD and Masters in Computer
Engineering from Sir Syed University of Engineering and
Technology (SSUET) Pakistan. She did Bachelors in Computer
Engineering from N.E.D. University, Pakistan. Rabia also did
Bachelors and Masters in Applied Mathematics from Karachi
University. She is an Associate Professor at the Department of
Computer Engineering at SSUET. Her research interests
include the conceptual frameworks and algorithms used in
Wireless Sensor Networks
Najma Ismat is a PhD scholar at Sir Syed University of
Engineering and Technology (SSUET) Pakistan. She has
received a Masters and BS in Computer Engineering from Sir
Syed University of Engineering and Technology (SSUET)
Pakistan in 2002 and 1998 respectively. She is Assistant
Professor in Department of Computer Engineering in SSUET.
Her research interests are mobility and reliability in ad hoc
wireless sensor networks