Treating Anxiety Disorders: Balancing the Real World and the Virtual World

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Barbara Olasov Rothbaum, PhD, is the Associate Vice Chair of Clinical Research in Emory School of Medicine’s Department of Psychiatry, a professor in the Department of Psychiatry and Behavioral Science, and director of Emory’s Veterans Program and Emory’s Trauma & Anxiety Recovery Program. Dr. Rothbaum specializes in treatment of anxiety disorders, with a focus on Post-Traumatic Stress Disorder (PTSD). With over 200 scientific publications, Rothbaum has changed the field of PTSD and was a forerunner in the use of virtual reality in treatment of anxiety disorders.

What initially drew you to the field of psychiatry?

I went to UNC-Chapel Hill as an undergrad. I actually went as a math major and that didn’t last long; My freshman year I decided to take a freshman seminar course, which meant there were only fifteen students, on how to design an experiment. It was a psychology course and I had no interest in psychology going in, but it sounded interesting. The course had the kind of teacher you always hope to have, or hope your kids have; the research bug bit me and I loved it. I kept taking more psychology classes and then got involved in research.

Who has influenced you the most in your career and why?

Barbara Rothbaum

Barbara Rothbaum

I learn every day. I learn every day from somebody, from every patient I see. When I think of real turning points; I think of my first professor my freshman year. He changed everything, I gave up all my math courses and went into psychology. When I was an undergraduate, I worked in a fetal alcohol lab under Carrie Randall, PhD, a professor at the Medical University of South Carolina, for a summer. I learned methodological control and precision from her. I also learned that I wanted to work with people after working with animals in Carrie’s lab. Working here at Emory with Michael Davis, PhD, Yerkes Researcher and Robert W. Woodruff Professor of Psychiatry, I started to get into translational research, asking questions of animals and then translating to humans and translating back to animals.

What was the process of integrating virtual reality and anxiety disorder work like?

In 1993, Larry Hodges, PhD, an Associate Professor in the College of Computing at Georgia Tech, contacted me about an Emory-Georgia Tech seed-grant program. Larry specialized in virtual reality and he found out that I was an exposure therapist, meaning that I help people confront their fears in a therapeutic manner. We originally wanted to do the research on fear of public speaking, but in the 1990s virtual reality was clunky. Virtual reality at the time worked more in angles, and people move in arcs. This made it difficult to do public speaking, so we decided to do fear of heights because of the angles and you can easily represent height in virtual reality. Our line at the time was, we “weren’t sure if we were on the cutting edge or the lunatic fringe.”

Could you describe the development process for the first virtual reality treatment incorporating computer scientists and clinical psychology?

Virtual Reality Therapy

Virtual Reality Therapy

I would go to Georgia Tech and I would explain exposure therapy to Larry’s brilliant computer science graduate students to help them understand why people get anxious. For example, we were working on the virtual airplane, there was just way too much room. About half the people who fear flying have a claustrophobia-focused fear that induces panic. Part of the trigger is feeling closed in so you need to remove the feeling of roominess. I would work with the programmers to help them understand the fear cues so they could go back and create them.

Your work has been brought to the marketplace through an Emory start-up Virtually Better – what was that experience like?

The first study was published in 1995, and the response was really amazing. Emory and Georgia Tech thought that there might be a marketable product, so they took us [as inventors] by the hand and drove us to a lawyer to incorporate, and that was Virtually Better. As soon as we incorporated, I received a letter saying that I had a conflict of interest since I was doing research in that area. That freaked me out, and I didn’t understand conflicts completely at the time. I ended up serving on the School of Medicine’s Conflict of Interest Committee for six years. It did limit my research for a while. Now we’ve learned how to manage conflicts; as a result I am able to do more research with virtual reality.

What types of challenges are there for the utilization and growth of virtual reality in psychiatry?

At Virtually Better, we often looked more like an academic department rather than a company trying to make money. This allowed us to get numerous grants, which supported more R&D. Every product we released had good data on efficacy. What scares me now is that people can be working on virtual reality in their garages. We have always had the input from clinical psychologists and computer scientists, we were cutting edge in both fields and releasing what we knew was a good product that a person can benefit from therapeutically. I worry now about quality control and efficacy.

Do you think virtual reality will be a game-changer in Post-Traumatic Stress Disorder (PTSD) treatment?

Well nothing works for everyone. One of the most important things we can have is alternatives and choices. Research has shown that if a patient with PTSD can choose their course of treatment they are more likely to respond positively. With this generation of veterans, which is a video generation, they tend to like virtual reality. It feels a little bit less like therapy to them and feels more “techie.” There was a study done with active duty military populations, that showed that people who feel less comfortable going to therapy would try virtual reality therapy.

What has been the personal satisfaction for you in seeing the progression in PTSD research and treatment?

It has been satisfying and challenging. When I started working in PTSD, there were no indicated treatments, it was just a diagnosis. Psychologists were extrapolating from other treatments for other anxiety disorders. It’s really nice to see that evidence-based treatments for PTSD exist now, but what’s still challenging is that none of them work for everyone. Also, I think some of it is the nature of the beast [with PTSD]. People with PTSD are avoidant; they don’t want to talk about it or go in for treatment. We need to not only develop effective treatments, but also acceptable treatments.

Many who work with PTSD, and other psychological disorders, experience burnout; how do you avoid burnout or compassion fatigue?

I exercise; I do yoga, I ride my bike. We talk about experiences at work in a group setting with supervision as part of the Emory Veterans program. There are some cases that we are talking about that bring tears to our eyes. It’s important that we are able to support each other, it’s not something you can go home and talk about over the dinner table. We hear the worst of the worst. So it’s about work-life balance.

What advice would you give to your younger self?

Problems and roadblocks used to really upset me. I now have the attitude that problems will occur daily, some large, some more manageable, and my job is to navigate them, so I can approach them with more equanimity, wisdom and creativity. I have also had to learn to not take things so personally, for example not receiving a grant or a paper rejection, and to bounce back and start working on the next one. I do give myself a little time (not more than a day) to “wallow” (I wouldn’t use that word for anyone else) following big disappointments. We are only human.

To learn more about Virtual Reality Therapy view our success story. To learn more about Virtually Better go to their website.