Virtual Reality Assisted Trauma Focused CBT

Background Northern Ireland is a country that has recently emerged from around 30 years of civil conflict that has resulted in the deaths of over 3500 people. This period known colloquially as 'The Troubles' has resulted in a legacy of trauma related mental health problems and has a higher estimated prevalence of Post-Traumatic Stress Disorder (PTSD) than any other comparable country that has experienced civil conflict. This has resulted in an estimated 39% of the population experiencing (directly or indirectly) a conflict related 'event'. PTSD has an estimated prevalence of 3.6% in the general world population, and a disproportionately high prevalence of 5.1% in among the Northern Ireland population.

Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) has been demonstrated to be an effective treatment for PTSD evolved from the Ehlers and Clark (2000) Cognitive Model of persistent PTSD. The evidence-based treatment of non-conflict related trauma such as sexual assault, road traffic accidents have highlighted the effectiveness and common acceptance of TF-CBT and is currently recommended by the NICE. as the first line of clinical treatment for PTSD. TF-CBT for individuals in Northern Ireland suffering from PTSD which has arisen from acts of terrorism and civil conflict has added to the emergent evidence base as a successful therapeutic intervention.

The model suggests that PTSD can develop if the patient continues to feel a sense of current threat after the trauma has ended, which can lead to further dysfunctional behaviours and feelings, even after the event has taken place. During the course of therapy, clients with PTSD revisits the trauma memory in order to fully process what has occurred. This technique is known as Imaginal Exposure (IE) via Reliving and whilst shown to be effective, IE can be a difficult process for clients given the associated, somatic and cognitive symptoms that it incurs. People diagnosed with PTSD can be highly avoidant and emotionally distant from trauma memories, meaning they find it challenging to engage with the exposure process. In addition, when trauma has occurred several decades previously, the trauma memory may be difficult to access or may have lost detail resulting in poor treatment outcomes.

Given the role of imaginal techniques within PTSD treatment, a growing number of studies have explored the use of immersive technology such as Virtual Reality (VR) to support this process. VR is no longer a futuristic concept and headsets are readily accessible, being used in many households for entertainment purposes. Currently there are many ways to create a virtual world and if used correctly can be therapeutically helpful to patients and clinicians. VR can generate environments such as social settings or classrooms that essentially simulate real or imagined worlds to meet the specific clinical requirement of the patient in therapy. Through use of VR, patients can enter a world in which they exposed to a traumatic memory in a controlled therapeutic way, and, in result, has shown to be effective in the treatment for PTSD patients across a number of settings such as military combat, terrorist attacks and road traffic accidents. Specific to military, in 2003, due to the deployments to Afghanistan and Iraq there was an increase in combat related PTSD in which the United States recognised the need to advance in evidence-based treatments to address these complexities.

Despite these successes we are yet to see the widespread adoption of VR based interventions for PTSD in routine clinical settings. Potential barriers are hypothesised to occur due to the idiosyncratic nature of the trauma memory, which requires the recreation of a personalised environment and thus has significant cost implications. Another barrier may be due the acceptability or lack thereof of these new technologies among clinicians.

Theoretical Framework The clinical presentation of PTSD is idiosyncratic; with specific symptoms experienced differing from individual to individual. Unwanted, intrusive, and involuntary distressing memories of the traumatic event are a core symptom of PTSD. Most successful treatment protocols for PTSD focus on the patient's memory of the traumatic event and its meaning. Therefore, a range of interventions have been developed to reduce the stress associated with these memories. Such interventions include Prolonged Exposure (PE), imaginal reliving of the trauma, and cognitive interventions to support the elaboration of traumatic memory to link with autobiographical memories. For this study, Ehlers and Clark's Cognitive Model of Persistent PTSD was used as a framework to develop the current treatment protocol.

In their cognitive model, Ehlers and Clark posit that chronic PTSD developed because individuals engage in sensory processing of the event rather than processing the meaning and implications. This causes disturbance in autobiographical memory, i.e., episodic (personal memories including places, objects, events) and semantic memory (memories about general knowledge and facts). Subsequently, this prevents the processing of trauma memories. They also postulated that individuals who experience PTSD develop excessively negative appraisals in which the probability of risk of harm is overestimated, and the ability to cope with threat is underestimated. Such maladaptive cognitive errors/biases cause avoidance of threats and provide short-term relief. These include avoiding trauma-related stimuli, remembering or suppressing unwanted trauma-related thoughts. However, in the long term, these activities maintain the sense of persistent threat as the coping strategies prevent negative appraisals from being corrected. Thus, the authors proposed that recalling the traumatic memories and updating them is the core of the trauma treatment. Ehlers and Clark's model follows the general style of reliving suggested by Foa and Rothbaum with some fluidity and in vivo exposure (i.e., trauma site visit). During the treatment process of reliving, clients are asked to close their eyes and intentionally recall the traumatic memories, i.e., relive the trauma in their mind in detail and narrate their experience in present tense, including recalling images, sensory experiences, thoughts, and feelings. VR-based PTSD treatments can promote emotional engagement and the process of trauma via providing visual, auditory, and haptic sensory cues.

Project Aim and Objectives

The study aims to explore the feasibility of integrating low-cost Virtual Reality (VR) Photoscan technology into Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) for individuals with Post-Traumatic Stress Disorder (PTSD). The goal is to assess whether this novel VR-assisted approach can enhance traditional therapy methods, making the intervention more accessible and practical within routine psychological services.

Objectives

1. To evaluate the feasibility of using low-cost Virtual Reality (VR) Photoscan technology alongside TF-CBT for adults with PTSD. This will include assessing the practicality of the technology's integration into clinical workflows within the Northern Health and Social Care Trust (NHSCT).
2. To gather data on participant recruitment, retention, and engagement throughout the study to understand the logistics of running the intervention in real-world clinical settings.
3. To train mental health professionals in the use of VR Photoscan technology and evaluate their ability to competently deliver TF-CBT with the added VR component.
4. To assess the acceptability, perceived benefits, and challenges of using VR Photoscan technology from the perspective of both clients and clinicians through qualitative interviews.
5. To explore the potential of using VR to enhance the therapy process, specifically during trauma reliving phases of TF-CBT, by providing a more immersive and controlled environment for exposure.
6. To conduct a preliminary power calculation based on the data gathered, to determine the appropriate sample size for a future, larger-scale randomized controlled trial (RCT) on the effectiveness of VR-assisted TF-CBT for PTSD.