Virtual Reality Exposure Therapy for Relapse Prevention in Substance Use Disorders
Introduction
Drug dependence is a chronic mental illness and 40-60 % of patients seeking treatment relapse within one year of seeking treatment according to a seminal study published in the Journal of American Medicine (McClellen et al., 2000). Clinicians and patients have long recognized the role of "triggers" in relapse, and the ability of a patient to effectively manage the cravings that triggers cause is paramount to a successful recovery. However, it could be reasonably argued that current efforts to prepare newly sober drug dependent patients for exposure to their triggers is inadequate, and this ineffective preparation contributes to unacceptably high rates of relapse.
“Holiday Triggers: Be mindful of previous triggers and possible new ones you may experience in the upcoming weeks. Write them out and jot down accompanying coping skills to get through them more easily.”
--- Bayside Marin email November 2019
The above email was sent from the clinical director of an esteemed treatment program to patients who had recently completed the program. It illustrates the state of current professional efforts to address trigger induced relapse and elucidates those efforts inadequacy. Despite the profound and well-known dangers posed by triggers around the holidays, the cornerstone of preparation is simply making a list and counseling patients to use certain techniques (deep breathing, making phone calls) when encountering the triggers. Despite the questionable efficacy of this approach, it is widely used in the recovery community, in part for lack of a more effective alternative for preparing patients for triggers. The recent development of Virtual Reality technologies provides a substantial opportunity for the clinician to augment current trigger induced relapse prevention strategies.
Cue Exposure Therapy
Starting to use drugs or drink alcohol after a period of sustained abstinence is an all to common occurrence colloquially referred to as "relapse." In many respects, the goal of the treatment of addiction is the prevention of relapse. Part of the challenge in successfully treating addiction is the myriad reasons that people will relapse, but a common reason, is that in the course of their sober lives people will encounter "triggers" that cause an urge to drink or use drugs. These triggers or cues are diverse, prevalent, and idiosyncratic. For an alcoholic, it can be as simple as seeing a friend drinking a glass of wine or being in a social situation associated with drinking such as a wedding. An alcoholic may have not had a drink for 6 months, then happens to stand next to a person drinking a glass of wine and is suddenly overwhelmed by an urge to drink himself, quickly forgetting the reasons he decided he needed to stop drinking
The phenomenon by which simply being exposed to an object or an environment can elicit an overwhelming urge for a sober alcoholic to drink has been hypothesized to be caused by learned behavior via
"Classical conditioning Ivan Pavlov in 1897,"
Classical conditioning is a theory of learning and behavior elegantly elucidated in a series of experiments conducted by physiologist " Ivan Pavlov in 1897 and is widely accepted as valid within the psychological community.
As with many important scientific discoveries, Pavlov's findings were in part serendipitous, as he had set out to study digestive fluids in dogs but ended up discovering a foundational concept of behavioral psychology. Pavlov was conducting a study in which he would give dogs raw meat and then measure their salivation. In the course of this study, he noticed that the dogs would begin to salivate at the sight of the technician that brought the raw meat to them. He hypothesized that the dogs had learned that seeing the technician meant that meat was soon to follow and therefore they began to salivate in anticipation.
Pavlov designed a set of simple experiments to test his hypothesis in which every time the dogs were given meat (unconditioned stimulus), a bell (conditioned stimulus) was sounded and salivation (conditioned response) was measured. After a period of time pairing the bell with the meat, he exposed the dogs to the sound of the bell without the meat present, finding that the sound of the bell alone now caused the dogs to salivate. Initially, the sound of the bell was neutral to the dogs and they had no reaction to it, however, after a period of time hearing the bell every time they were fed meat, the dogs developed a physiological reaction to the sound of the bell alone: they salivated. This learned behavior was termed "classical conditioning" and is taught in every Introduction to Psychology class over a century later.
Learned behavior and classical conditioning concepts have obvious implications in understanding addictive behaviors, and particularly trigger induced relapse. A poignant example is Mike, a recently "clean" intravenous heroin addict who now reports the sight of hypodermic needles as a trigger. In the years preceding his addiction to heroin, he had a neutral reaction to the sight of a hypodermic needle, he regarded them as he would any other object in the doctor's office. However, after years of IV heroin use, in which he used similar needles to inject heroin, the sight of a hypodermic needle now caused an overwhelming urge to use heroin, even causing his heart rate to increase and his palms to sweat. A previously neutral stimulus (sight of a needle) has become strongly associated with the feeling of a heroin high, just as a bell had become strongly associated with the taste of meat for Pavlov's dogs.
Previously neutral stimuli, such as visual, auditory, and olfactory cues become so strongly associated with the drug that it can trigger a conditioned response (intense drug craving). Through the process of associative learning, both the drug and associated stimuli can evoke the same unconditioned and conditioned response, which over time will elicit trigger induced cravings, causing addictive behavior (Everitt & Robbins, 2005). The example of a hypodermic needle is a simple example, and it might be argued that one could just avoid seeing needles. However, for an alcoholic seeking to abstain from drinking, these triggers are diverse, prevalent, and to certain extent unavoidable. Alcoholic beverages are advertised enthusiastically, bottles displayed prominently in grocery stores, and alcohol is used liberally in social settings
Maybe: DJ AM antetote – 9 years sober, pipe holding, relapse, overdeose , NYT interview
Sinclaire Method etc
Cue Exposure Therapy (CET) is a controversial treatment strategy employed for the prevention of relapse. In this behavioral psychological approach, individuals are repeatedly exposed to drug cues or "triggers" without using the drug in the hopes of extinguishing the learned response to these triggers (Conklin and Tiffany 2002). In other words, the goal is to break the learned association between triggering objects (needles) or environments (weddings) and the addict's drug of choice, thereby allowing newly sober individuals to safely navigate exposure to these triggers in the course of their lives.
This approach is based on another tenet of classical conditioning referred to as "extinction." Follow up experiments to Pavlov's finding showed that dogs that were conditioned to salivate at the sound of a bell, could unlearn this response through repeated exposure to the bell in the absence of meat. In short, a dog would initially have no response to the sound of a bell, then would learn to associate the bell with meat through repeated pairing of the two, and this learning could subsequently be "extinguished" through repeated exposure to the bell without the meat.
The goal of CET in the context of relapse prevention is to extinguish the conditioned response (craving or use) to triggers through repeated "non-reinforced exposure" (Marlett 2005). The idea is that that repeated exposure to triggers without using drugs will over time break this association. It follows that CET is a rational approach for the prevention of trigger induced relapse as it aims to prepare the addict to cope with trigger induced craving produced by either exposure to the drug or conditioned stimuli. (Mellentin, 2017)
CET has been applied in the treatment of a variety of abused substances including tobacco (Niaura et al 1988), alcohol (Rohsenow et al, 2001) and opiates (Colby et al., 2001). However, recent systematic literature reviews have concluded that evidence for the effectiveness of CET in relapse prevention is mixed at best (Conklin and Tiffany, 2002). Reword Despite a prima-facie rational for the use of CET in the treatment of substance use disorders, its use has fallen out of favor in part because in has been ineffective.
Therapy
Conklin and Tiffany posited that the ineffectiveness of CET in the treatment of substance abuse was due to unrealistic cue exposure in hospital or clinical settings. In these studies, CET may have failed to prevent relapse because the treatments involved just one unrealistic cue, and the extinction of one cue could not be generalized to others. For example, a photo of a bottle of alcohol effectively reduced cravings triggered by photograph of a bottle of alcohol, but it would not attenuate craving induced by the myriad of complex cues encountered in the real world. Furthermore, most CET studies in substance abuse were conducted in hospital or academic laboratory settings, which did not effectively simulate the environmental triggers that a person would encounter. Viewing a photograph of a bottle of alcohol while sitting in a hospital, may not be sufficiently similar to viewing a real bottle of alcohol in a grocery store. In sum, despite a compelling rational for the use of CET for the prevention of trigger induced relapse, CET effectiveness in this setting has been disappointing, and the reason may be insufficiently realistic cues in the Cue Exposure Therapy protocol.
Virtual reality technology offers a new opportunity to address these short comings by providing a realistic and diverse range of situations and stimuli. Rather than exposing patients to a still photo of a glass of wine while sitting in a hospital, patients can now be exposed to a realistic simulation of walking into a bar with an accurate depiction of associated sights, sounds and smells.
There is already considerable precedent for using virtual reality technology in CET protocols. Virtual Reality Exposure Therapy (VRET) has been extensively studied in numerous mental health disorders. VRET has been shown to be efficacious in the treatment of specific phobias (Rothbaum et al. 2000, Botella et al 2014), social anxiety (Anderson et al 2013, Bouchard et al 2016), and in the treatment of Post-Traumatic Stress Disorder (Rizzo et al 2009).
VRET has shown to be particularly effective in combat related PTSD as demonstrated by Reger et. al in a study of veterans recently returning from combat duty in Iraq whom were struggling with debilitating PTSD symptoms. Six sessions of VRET were provided using an immersive simulation of a military convoy in Iraq. Self-reported PTSD symptoms and psychological distress were reduced at posttreatment relative to pretreatment reports, as assessed by the PTSD Checklist-Military Version and the Behavior and Symptom Identification Scale-24. (Reger et al 2008). In this study, patients had a therapist present to guide them through the VRET simulations to great effect. It has been suggested that VRET combined with therapist guided "coping skills training" should be the standard of care in the treatment of PTSD. (Reger, reference #2)
It is not hard to imagine how this approach could be extended to trigger induced relapse prevention. For instance, abstinent alcoholics could be repeatedly exposed to a realistic simulation of being in an environment such as a wedding where drinking cues are prevalent, and then be guided through the simulations by a therapist. Virtual Reality would allow for the customization of scenarios that are triggering to the individual patient. The hope being that repeated exposure to realistic simulations of these scenarios, combined with skills to cope with them, would reduce the occurrence of trigger induced relapse.
The veterans in the above PTSD study were repeatedly exposed to virtual environments that triggered their conditioned response (fear, anxiety), and with coping skills provided by a therapist, learned to extinguish this response. It follows that newly sober alcohol or drug dependent patients may benefit from repeated virtual exposure to their "triggers" while being guided through these simulations by a trained professional.
What is done now, trigger list etc.
Given the impressive amount of empirical evidence supporting the use of VRET in a multitude of mental health disorders, it is surprising to find that the use of VRET in the treatment of substance abuse has been limited to this point. Virtual reality technology has the potential to present individuals with accurate simulations of the triggers that often drive relapse after a period of abstinence. Repeated exposure to realistic simulations of triggering cues and environments may reduce the conditioned response (craving) to these cues, as it has been shown to do in PTSD patients described above.
Despite the paucity of investigation into the use of VRET for trigger induced relapse prevention, several studies have elucidated the ability of VR to effectively invoke cravings in a range of substances: alcohol (Lee et al 2008), cocaine (Saladin et. al, 2016), and nicotine (Bordnick et al, 2005, Perlcot et al, 2016).
A 2008 VRET study by Lee et al at the School of Medicine, University of Seoul South Korea was particularly interesting as it showed that VR rendered alcohol cues elicited enormous cravings in alcohol dependent subjects, but not in age matched "social drinkers." In this study, 15 people currently residing in an in-patient treatment program whom met the DSM-IV criteria for alcohol dependence were age matched with 15 individuals that did not meet the criteria for alcohol use disorder. Both groups were fitted with virtual reality headsets and shown a virtual pub with several virtual alcohol cues present (a glass filled with alcohol, a bottle of alcohol, and an advertisement for alcohol). The craving levels were measured before and after exposure on a percent scale from "I do not want to drink (0%)" to "My desire to drink is unbearable (100%)." The VR induced craving level was determined by calculating the difference between the craving rating before and after the VR exposure. The VR cues elicited a strong craving in alcohol dependent patients but only nominal cravings in non-dependent controls. The difference between groups was profound, alcoholics shown virtual reality rendered triggers reported a five-fold increase in craving level as compared to "normal" subjects. (Lee et. al 2008). This study demonstrated that VR exposure to triggers is very effective in eliciting cravings in alcoholics, but it did not examine the effects of repeated exposure or attempt to "extinguish" the association between trigger/cue and alcohol.
The proven ability of VR to effectively elicit cravings in alcohol dependent patients suggests that VR has the potential to be successfully used in CET paradigms for relapse prevention, though this has yet to have been rigorously demonstrated. Repeated non reinforced exposure to realistic triggers may reduce trigger induced cravings, ameliorating the shortcomings of CET use in substance abuse disorders by providing heretofore unavailable realistic cues. The effectiveness of VRET in smoking cessation has already been conclusively demonstrated. Recent studies have shown the effectiveness of VRET for reducing trigger induced cravings in nicotine dependent patients and have demonstrated that this approach is more effective in eliciting conditioned responses than are conventional methods such as slides or video (Park 2014, Bauman 2006).
There is some evidence in the literature that VRET may be effective in reducing trigger induced cravings in alcoholic patients. A small pilot study has shown that repeated exposure to VR alcohol cues reduce the cravings elicited by the cues after repeated exposure in alcoholic patients (Yang et. al 2008). In this study 10 alcoholic patients were exposed to VR rendered alcohol cues for 7 successive sessions and their cravings evaluated by the Alcohol Urge Questionnaire after each session and found moderate (30%) statistically significant reduction in reported cue induced craving level. This study was small, uncontrolled, and importantly, these subjects were given no supportive therapy, just virtual reality exposure and the study was poorly powered and designed.
In sum, newly sober alcohol or drug dependent patients often relapse after exposure to their triggers. The ability of triggers to cause strong cravings in sober alcoholics is thought to be based on associative learning and classical conditioning. In the past, clinicians have attempted to use cue exposure therapy to extinguish the association between triggers and the abused substance, hoping to reduce trigger induced relapse. These efforts have met with mixed results likely due to the limited and unrealistic cues used in cue exposure therapy treatment protocols. Virtual reality technology can provide the clinician with a means to address these short comings by repeatedly exposing the patients to realistic and immersive triggering situations in a way that was not previously possible. Combining virtual reality cue exposure therapy with therapist guided coping skills training offers a novel and sophisticated approach trigger induced relapse prevention.
Potential Use for VR in Cognitive Behavioral Therapy for Relapse Prevention
Rehearsal of these cognitive restructuring skills in the context of drug cues may enhance the availability of these skills outside the treatment setting. (Otto et al 2007).
Frequently asked quetions
TriggerWalk’s use of aromas is rooted in neuropsychology. Although the human response to smell is weak, its subconscious effects remain intense and valid across a wide range of persons suffering from addiction and trauma. The alcoholic develops a keen sense of smell for alcohol and the victim of a car crash develops PTSD triggered by gasoline. The ability to smell is tightly linked with memory recall, as studies have shown, thus we found it necessary to add scent dissemination to our platform’s arsenal of tools to aid recovery
VR-TriggerWalks platform utilizes VR technology and non-reactive perfumes to replicate real world environments, which are crafted with care and attention to the trigger (and its severity) the therapist wishes to portray to their patient. Furthermore, any number of choices may be implemented into the environment, giving the subject a sense of control and autonomy—elements hard to come by in most rehabilitation facilities. By exposing these clients to their triggers, over a course of 4 to 8 weeks, they, and their therapist, may better understand both the psychological and physiological responses to such triggers, thus becoming desensitized and better able to manage these responses.
To help those in recovery to recognize and process triggers in support of a more successful recovery and reduce the risk of relapse. Our goal is to be able to offer this as a commonly used therapy in all clinical environments. We plan to evolve as the technology evolves in order to utilize these new tools to their fullest potential. TriggerWalk seeks to help those in need who have no way to safely experience the outside world when they are comfortable and safe within the isolated walls of a hospital, prison, recovery center, or therapist's office.
Virtual Reality Exposure Therapy for Relapse Prevention in Substance Use Disorders
Introduction
Drug dependence is a chronic mental illness and 40-60 % of patients seeking treatment relapse within one year of seeking treatment according to a seminal study published in the Journal of American Medicine (McClellen et al., 2000). Clinicians and patients have long recognized the role of "triggers" in relapse, and the ability of a patient to effectively manage the cravings that triggers cause is paramount to a successful recovery. However, it could be reasonably argued that current efforts to prepare newly sober drug dependent patients for exposure to their triggers is inadequate, and this ineffective preparation contributes to unacceptably high rates of relapse.
“Holiday Triggers: Be mindful of previous triggers and possible new ones you may experience in the upcoming weeks. Write them out and jot down accompanying coping skills to get through them more easily.”
--- Bayside Marin email November 2019
The above email was sent from the clinical director of an esteemed treatment program to patients who had recently completed the program. It illustrates the state of current professional efforts to address trigger induced relapse and elucidates those efforts inadequacy. Despite the profound and well-known dangers posed by triggers around the holidays, the cornerstone of preparation is simply making a list and counseling patients to use certain techniques (deep breathing, making phone calls) when encountering the triggers. Despite the questionable efficacy of this approach, it is widely used in the recovery community, in part for lack of a more effective alternative for preparing patients for triggers. The recent development of Virtual Reality technologies provides a substantial opportunity for the clinician to augment current trigger induced relapse prevention strategies.
Cue Exposure Therapy
Starting to use drugs or drink alcohol after a period of sustained abstinence is an all to common occurrence colloquially referred to as "relapse." In many respects, the goal of the treatment of addiction is the prevention of relapse. Part of the challenge in successfully treating addiction is the myriad reasons that people will relapse, but a common reason, is that in the course of their sober lives people will encounter "triggers" that cause an urge to drink or use drugs. These triggers or cues are diverse, prevalent, and idiosyncratic. For an alcoholic, it can be as simple as seeing a friend drinking a glass of wine or being in a social situation associated with drinking such as a wedding. An alcoholic may have not had a drink for 6 months, then happens to stand next to a person drinking a glass of wine and is suddenly overwhelmed by an urge to drink himself, quickly forgetting the reasons he decided he needed to stop drinking
The phenomenon by which simply being exposed to an object or an environment can elicit an overwhelming urge for a sober alcoholic to drink has been hypothesized to be caused by learned behavior via
"Classical conditioning Ivan Pavlov in 1897,"
Classical conditioning is a theory of learning and behavior elegantly elucidated in a series of experiments conducted by physiologist " Ivan Pavlov in 1897 and is widely accepted as valid within the psychological community. As with many important scientific discoveries, Pavlov's findings were in part serendipitous, as he had set out to study digestive fluids in dogs but ended up discovering a foundational concept of behavioral psychology. Pavlov was conducting a study in which he would give dogs raw meat and then measure their salivation. In the course of this study, he noticed that the dogs would begin to salivate at the sight of the technician that brought the raw meat to them. He hypothesized that the dogs had learned that seeing the technician meant that meat was soon to follow and therefore they began to salivate in anticipation. Pavlov designed a set of simple experiments to test his hypothesis in which every time the dogs were given meat (unconditioned stimulus), a bell (conditioned stimulus) was sounded and salivation (conditioned response) was measured. After a period of time pairing the bell with the meat, he exposed the dogs to the sound of the bell without the meat present, finding that the sound of the bell alone now caused the dogs to salivate. Initially, the sound of the bell was neutral to the dogs and they had no reaction to it, however, after a period of time hearing the bell every time they were fed meat, the dogs developed a physiological reaction to the sound of the bell alone: they salivated. This learned behavior was termed "classical conditioning" and is taught in every Introduction to Psychology class over a century later.
Learned behavior and classical conditioning concepts have obvious implications in understanding addictive behaviors, and particularly trigger induced relapse. A poignant example is Mike, a recently "clean" intravenous heroin addict who now reports the sight of hypodermic needles as a trigger. In the years preceding his addiction to heroin, he had a neutral reaction to the sight of a hypodermic needle, he regarded them as he would any other object in the doctor's office. However, after years of IV heroin use, in which he used similar needles to inject heroin, the sight of a hypodermic needle now caused an overwhelming urge to use heroin, even causing his heart rate to increase and his palms to sweat. A previously neutral stimulus (sight of a needle) has become strongly associated with the feeling of a heroin high, just as a bell had become strongly associated with the taste of meat for Pavlov's dogs.
Previously neutral stimuli, such as visual, auditory, and olfactory cues become so strongly associated with the drug that it can trigger a conditioned response (intense drug craving). Through the process of associative learning, both the drug and associated stimuli can evoke the same unconditioned and conditioned response, which over time will elicit trigger induced cravings, causing addictive behavior (Everitt & Robbins, 2005). The example of a hypodermic needle is a simple example, and it might be argued that one could just avoid seeing needles. However, for an alcoholic seeking to abstain from drinking, these triggers are diverse, prevalent, and to certain extent unavoidable. Alcoholic beverages are advertised enthusiastically, bottles displayed prominently in grocery stores, and alcohol is used liberally in social settings
Maybe: DJ AM antetote – 9 years sober, pipe holding, relapse, overdeose , NYT interview
Sinclaire Method etc
Cue Exposure Therapy (CET) is a controversial treatment strategy employed for the prevention of relapse. In this behavioral psychological approach, individuals are repeatedly exposed to drug cues or "triggers" without using the drug in the hopes of extinguishing the learned response to these triggers (Conklin and Tiffany 2002). In other words, the goal is to break the learned association between triggering objects (needles) or environments (weddings) and the addict's drug of choice, thereby allowing newly sober individuals to safely navigate exposure to these triggers in the course of their lives.
This approach is based on another tenet of classical conditioning referred to as "extinction." Follow up experiments to Pavlov's finding showed that dogs that were conditioned to salivate at the sound of a bell, could unlearn this response through repeated exposure to the bell in the absence of meat. In short, a dog would initially have no response to the sound of a bell, then would learn to associate the bell with meat through repeated pairing of the two, and this learning could subsequently be "extinguished" through repeated exposure to the bell without the meat.
The goal of CET in the context of relapse prevention is to extinguish the conditioned response (craving or use) to triggers through repeated "non-reinforced exposure" (Marlett 2005). The idea is that that repeated exposure to triggers without using drugs will over time break this association. It follows that CET is a rational approach for the prevention of trigger induced relapse as it aims to prepare the addict to cope with trigger induced craving produced by either exposure to the drug or conditioned stimuli. (Mellentin, 2017)
CET has been applied in the treatment of a variety of abused substances including tobacco (Niaura et al 1988), alcohol (Rohsenow et al, 2001) and opiates (Colby et al., 2001). However, recent systematic literature reviews have concluded that evidence for the effectiveness of CET in relapse prevention is mixed at best (Conklin and Tiffany, 2002). Reword Despite a prima-facie rational for the use of CET in the treatment of substance use disorders, its use has fallen out of favor in part because in has been ineffective.
Therapy Conklin and Tiffany posited that the ineffectiveness of CET in the treatment of substance abuse was due to unrealistic cue exposure in hospital or clinical settings. In these studies, CET may have failed to prevent relapse because the treatments involved just one unrealistic cue, and the extinction of one cue could not be generalized to others. For example, a photo of a bottle of alcohol effectively reduced cravings triggered by photograph of a bottle of alcohol, but it would not attenuate craving induced by the myriad of complex cues encountered in the real world. Furthermore, most CET studies in substance abuse were conducted in hospital or academic laboratory settings, which did not effectively simulate the environmental triggers that a person would encounter. Viewing a photograph of a bottle of alcohol while sitting in a hospital, may not be sufficiently similar to viewing a real bottle of alcohol in a grocery store. In sum, despite a compelling rational for the use of CET for the prevention of trigger induced relapse, CET effectiveness in this setting has been disappointing, and the reason may be insufficiently realistic cues in the Cue Exposure Therapy protocol.
Virtual reality technology offers a new opportunity to address these short comings by providing a realistic and diverse range of situations and stimuli. Rather than exposing patients to a still photo of a glass of wine while sitting in a hospital, patients can now be exposed to a realistic simulation of walking into a bar with an accurate depiction of associated sights, sounds and smells.
There is already considerable precedent for using virtual reality technology in CET protocols. Virtual Reality Exposure Therapy (VRET) has been extensively studied in numerous mental health disorders. VRET has been shown to be efficacious in the treatment of specific phobias (Rothbaum et al. 2000, Botella et al 2014), social anxiety (Anderson et al 2013, Bouchard et al 2016), and in the treatment of Post-Traumatic Stress Disorder (Rizzo et al 2009).
VRET has shown to be particularly effective in combat related PTSD as demonstrated by Reger et. al in a study of veterans recently returning from combat duty in Iraq whom were struggling with debilitating PTSD symptoms. Six sessions of VRET were provided using an immersive simulation of a military convoy in Iraq. Self-reported PTSD symptoms and psychological distress were reduced at posttreatment relative to pretreatment reports, as assessed by the PTSD Checklist-Military Version and the Behavior and Symptom Identification Scale-24. (Reger et al 2008). In this study, patients had a therapist present to guide them through the VRET simulations to great effect. It has been suggested that VRET combined with therapist guided "coping skills training" should be the standard of care in the treatment of PTSD. (Reger, reference #2)
It is not hard to imagine how this approach could be extended to trigger induced relapse prevention. For instance, abstinent alcoholics could be repeatedly exposed to a realistic simulation of being in an environment such as a wedding where drinking cues are prevalent, and then be guided through the simulations by a therapist. Virtual Reality would allow for the customization of scenarios that are triggering to the individual patient. The hope being that repeated exposure to realistic simulations of these scenarios, combined with skills to cope with them, would reduce the occurrence of trigger induced relapse. The veterans in the above PTSD study were repeatedly exposed to virtual environments that triggered their conditioned response (fear, anxiety), and with coping skills provided by a therapist, learned to extinguish this response. It follows that newly sober alcohol or drug dependent patients may benefit from repeated virtual exposure to their "triggers" while being guided through these simulations by a trained professional.
What is done now, trigger list etc. Given the impressive amount of empirical evidence supporting the use of VRET in a multitude of mental health disorders, it is surprising to find that the use of VRET in the treatment of substance abuse has been limited to this point. Virtual reality technology has the potential to present individuals with accurate simulations of the triggers that often drive relapse after a period of abstinence. Repeated exposure to realistic simulations of triggering cues and environments may reduce the conditioned response (craving) to these cues, as it has been shown to do in PTSD patients described above.
Despite the paucity of investigation into the use of VRET for trigger induced relapse prevention, several studies have elucidated the ability of VR to effectively invoke cravings in a range of substances: alcohol (Lee et al 2008), cocaine (Saladin et. al, 2016), and nicotine (Bordnick et al, 2005, Perlcot et al, 2016).
A 2008 VRET study by Lee et al at the School of Medicine, University of Seoul South Korea was particularly interesting as it showed that VR rendered alcohol cues elicited enormous cravings in alcohol dependent subjects, but not in age matched "social drinkers." In this study, 15 people currently residing in an in-patient treatment program whom met the DSM-IV criteria for alcohol dependence were age matched with 15 individuals that did not meet the criteria for alcohol use disorder. Both groups were fitted with virtual reality headsets and shown a virtual pub with several virtual alcohol cues present (a glass filled with alcohol, a bottle of alcohol, and an advertisement for alcohol). The craving levels were measured before and after exposure on a percent scale from "I do not want to drink (0%)" to "My desire to drink is unbearable (100%)." The VR induced craving level was determined by calculating the difference between the craving rating before and after the VR exposure. The VR cues elicited a strong craving in alcohol dependent patients but only nominal cravings in non-dependent controls. The difference between groups was profound, alcoholics shown virtual reality rendered triggers reported a five-fold increase in craving level as compared to "normal" subjects. (Lee et. al 2008). This study demonstrated that VR exposure to triggers is very effective in eliciting cravings in alcoholics, but it did not examine the effects of repeated exposure or attempt to "extinguish" the association between trigger/cue and alcohol.
The proven ability of VR to effectively elicit cravings in alcohol dependent patients suggests that VR has the potential to be successfully used in CET paradigms for relapse prevention, though this has yet to have been rigorously demonstrated. Repeated non reinforced exposure to realistic triggers may reduce trigger induced cravings, ameliorating the shortcomings of CET use in substance abuse disorders by providing heretofore unavailable realistic cues. The effectiveness of VRET in smoking cessation has already been conclusively demonstrated. Recent studies have shown the effectiveness of VRET for reducing trigger induced cravings in nicotine dependent patients and have demonstrated that this approach is more effective in eliciting conditioned responses than are conventional methods such as slides or video (Park 2014, Bauman 2006).
There is some evidence in the literature that VRET may be effective in reducing trigger induced cravings in alcoholic patients. A small pilot study has shown that repeated exposure to VR alcohol cues reduce the cravings elicited by the cues after repeated exposure in alcoholic patients (Yang et. al 2008). In this study 10 alcoholic patients were exposed to VR rendered alcohol cues for 7 successive sessions and their cravings evaluated by the Alcohol Urge Questionnaire after each session and found moderate (30%) statistically significant reduction in reported cue induced craving level. This study was small, uncontrolled, and importantly, these subjects were given no supportive therapy, just virtual reality exposure and the study was poorly powered and designed.
In sum, newly sober alcohol or drug dependent patients often relapse after exposure to their triggers. The ability of triggers to cause strong cravings in sober alcoholics is thought to be based on associative learning and classical conditioning. In the past, clinicians have attempted to use cue exposure therapy to extinguish the association between triggers and the abused substance, hoping to reduce trigger induced relapse. These efforts have met with mixed results likely due to the limited and unrealistic cues used in cue exposure therapy treatment protocols. Virtual reality technology can provide the clinician with a means to address these short comings by repeatedly exposing the patients to realistic and immersive triggering situations in a way that was not previously possible. Combining virtual reality cue exposure therapy with therapist guided coping skills training offers a novel and sophisticated approach trigger induced relapse prevention. Potential Use for VR in Cognitive Behavioral Therapy for Relapse Prevention
Rehearsal of these cognitive restructuring skills in the context of drug cues may enhance the availability of these skills outside the treatment setting. (Otto et al 2007).
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Frequently asked quetions
TriggerWalk’s use of aromas is rooted in neuropsychology. Although the human response to smell is weak, its subconscious effects remain intense and valid across a wide range of persons suffering from addiction and trauma. The alcoholic develops a keen sense of smell for alcohol and the victim of a car crash develops PTSD triggered by gasoline. The ability to smell is tightly linked with memory recall, as studies have shown, thus we found it necessary to add scent dissemination to our platform’s arsenal of tools to aid recovery
VR-TriggerWalks platform utilizes VR technology and non-reactive perfumes to replicate real world environments, which are crafted with care and attention to the trigger (and its severity) the therapist wishes to portray to their patient. Furthermore, any number of choices may be implemented into the environment, giving the subject a sense of control and autonomy—elements hard to come by in most rehabilitation facilities. By exposing these clients to their triggers, over a course of 4 to 8 weeks, they, and their therapist, may better understand both the psychological and physiological responses to such triggers, thus becoming desensitized and better able to manage these responses.
To help those in recovery to recognize and process triggers in support of a more successful recovery and reduce the risk of relapse. Our goal is to be able to offer this as a commonly used therapy in all clinical environments. We plan to evolve as the technology evolves in order to utilize these new tools to their fullest potential. TriggerWalk seeks to help those in need who have no way to safely experience the outside world when they are comfortable and safe within the isolated walls of a hospital, prison, recovery center, or therapist's office.
