Using Virtual Reality as a Training Tool to Enhance the Proficiency of Behavioral Health Providers

Posted November 6, 2020

Hazel R. Atuel, Ph.D., University of Southern California

Hazel R. Atuel, Ph.D., University of Southern California

Dr. Hazel R. Atuel

Twenty percent of Service members have a diagnosed combat or other military-related behavioral health problem and, of that percentage, nearly half do not receive any form of treatment.[1] One reason for this is the shortage of trained behavioral health providers (BHPs). Dr. Hazel Atuel, with funding from the Defense Medical Research and Development Program’s Broad Agency Announcement, sought to address this gap in clinical practice by creating two pilot studies aimed at increasing the competency of current and future BHPs using current technology such as virtual reality platforms. Study A sought to further the development of the Virtual Client-Trainer (VC-T) by expanding the utility and capacity of the virtual patient and evaluate its efficacy as a practice training tool compared to other standard methods, such as Student Peer-to-Peer Role Play (SPPRP) and Standardized Actor Client (SAC). Study B focused on the development of a virtual Military Practitioner Training Program (MPTP) that promotes maintenance of clinical knowledge and practice behavior related to Cognitive Processing Therapy – Cognitive Only (CPT-C, now simply known as CPT), and the adoption of CPT-C over time. The MPTP consists of virtual CPT-C workshops, a CPT-C mobile application, and virtual coaching. 

Using Virtual Client software, the VC-T has modules for suicide and post-traumatic stress disorder, as well as a client engagement/rapport-building modules. These VC-T modules have voice recognition integration, instructor character systems, and avatar emotion animation systems. A “Tell Me More” feature was developed, which allows the user to have further dialogue based on that specific virtual client’s health (e.g., sleep issues or alcohol use). The VC-T system was compared to the more standard trainings of SPPRP and SAC by assessing graduate students using pre- and post-tests. Participants in both SPPRP and SAC were observed to have improved from pre-test to post-test on developing a collaborative relationship with the military client, recognizing and responding to PTSD symptoms, recognizing and responding to suicidal symptoms, and overall performance. When comparing VC-T and the SPPRP training modalities, no significant differences emerged in the pre-test and post-test results for self-efficacy, engagement, identifying PTSD and suicide symptoms, and competence, although both groups’ performances improved on the post-test in recognizing PTSD and suicidal symptoms. Their results showed that SPPRP and VC-T appear to be equally effective training modules. 

In Study B, participants described positive experiences with the CPT-C virtual training program’s structure, including homework assignments and workshop length. The workshop structure of lecture followed by small-group practice with Standardized Actor Patients (SAPs) was assessed as helpful in facilitating learning and skill-building. The process and outcome of the virtual CPT-C workshops were published in Military Medicine.[2] In addition, the process and barriers to implementation of CPT-C are discussed in an article currently under review. 

The evidence that virtual training can prepare current and future BHP as well as SPPRP or SAC puts healthcare one step closer to seeing that our Service members receive the treatments they need. 


[1] Tanelian T and Jaycox LH (Eds.). 2008. Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. RAND Corporation. Santa Monica, CA: Also available in print form. 

[2] Atuel HR, Ursich L, Schuyler A, et al. 2019. Implementing the Knowledge Assessment of CPT-C Critical Skills (KACCS) Scale. Military Medicine 184:461-466. 


Kintzle S, Munch C, Alday E, et al. 2018. The use of virtual clients for training behavioral health providers: Promises, challenges and the way ahead. Journal of Technology in Behavioral Science. Advance online publication. 


Technical Abstract: Virtual Reality as a Tool for Enhancing the Proficiency of Behavioral Health Providers

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