This study was approved by the Ben Taub Hospital IRB, and each participant signed a consent form, and gave written permission to publish their de-identified results. The participants were not compensated for their participation in this study. Patient 1 was a 39-year-old male patient hospitalized with a traumatic SCI C4-5 resulting in quadriplegia and respiratory failure requiring trachiotomy (breathing through a hole in his throat) after falling out of 4 story building (apparent suicide attempt) 2 weeks prior to the current study. The fall/accident resulted in C6/C7 Burst Fracture, C4/C5 Spinous Process Fractures, C5/C6 Transverse Process Fractures, SCI, and right 8th through 11th rib fractures. Psychological assessments determined that the patient was clinically depressed, and had high anxiety associated with the traumatic event that left him paralyzed with a SCI. He could not remember anything about events leading up to his fall out of a building and he did not have any PTSD symptoms.
Patient 2 suffered a SCI after jumping out of a moving vehicle, in an attempted suicide. Due to damage to the spine including a C7 fracture, the hospitalized patient had bilateral hand numbness and parasthesias, and paresis (partial paralysis of his legs). Both patients were treated by the first author of this paper (AF). The psychotherapist (AF) has a Ph.D. in clinical psychology and had been working with SCI patients as a clinical psychologist at Ben Taub for several years, at the time this study was conducted.
This was a within-subject design case study with key measures administered before and after each VR DBT  mindfulness training session. Patients received VR DBT  Mindfulness training sessions after they were cleared by the acute surgery team to participate in this study. Patients were also free from infection at the time of the intervention. The measures were administered before and after each VR intervention. During the VR+DBT  skills learning interventions, the participant looked into a pair of wide field of view Oculus Rift DK2 VR goggles (100  field of view diagonal, per eye), and had the illusion of floating down a 3-D computer-generated river (created and owned by bigenvironments.com, see also vrpain.com) while listening to one of three DBT  mindfulness skills training audio tracks. All audio tracks and verbal DBT  treatments used in this study are copyrighted by Marsha Linehan. See below a brief description of each audio track as well as the VR system.
Track 1: Observing Sound (Linehan,; 8.5 min total).
Here is an excerpt "what we are going to do now is practice observing sound....the idea is not to think about sound, the idea is to just notice it...I am going to start by ringing the bell three times....just listen to the bells, how long they last, how they go from loud to soft, just listen, as you focus on your breath coming in and breath coming out. If your mind wanders, bring it back."
Track 2: Observing visuals: (adapted from Linehan,; 10 min total)
The observing visuals script was adapted to synchronize with images the patient sees in the VR goggles when they are listening to the audio (Navarro-Haro et al.,).
Exerpt: "Notice what you see as you float down the river, observe the serenity of the water, attend to what you see in the present moment. If your mind wanders away, just bring it back, gently...to the river."
Track 3: Wise Mind; (adapted from Linehan,; 8 min long)
The patient listened to these audio instructions while in VR floating down the river in virtual reality. Here is an excerpt "Imagine that you are a small flake of stone, flat, and light. You are now floating slowly and gently through the clear blue water, toward your wise mind...notice what you see, what you feel, as you are floating down toward your wise mind. As you float down the river, observe the serenity of the river, be aware of the calmness, and settle your attention there, within yourself." "As you reach the center of your self, focus your attention there, in your center, in your wise mind. Come back...to the river..if you find your mind wandering."
Each participant sat in their hospital bed. After filling out the pre-treatment psychological measures, the patient looked into a pair of Oculus Rift DK2 VR goggles. Patient one had a breathing tube in his neck, and was not allowed to move his head, so the therapist held the VR goggles near his face. Patient 2 wore the VR goggles on his head, and was able to look around in the VR world. Head tracking allowed him to look around the 3D computer virtual world.
While looking into the virtual reality goggles, each patient looked down river. Near the beginning of the VR session, the patients stayed in one place at the top of the virtual river, as they received verbal DBT  mindfulness skills training exercise instructions from the therapist. Then, the patient began descending slowly down the river while listening to audio instructions directing the patient how to practice mindfulness. Each participant sat in their hospital bed and looked into a pair of head mounted Oculus Rift DK2 VR goggles with 100  diagonal field of view per eye and 960 by 1,080 pixels resolution per eye (75 hz). The goggles were plugged into an MSI GT Series GT72 Dominator Pro G-1252 Gaming Laptop 6th Generation Intel Core i7 6700HQ (2.60 GHz) 16 GB Memory 1 TB HDD 512 GB SSD NVIDIA GeForce GTX 980M 4 GB GDDR5 17.3" Windows 10 Home 64-Bit. The VR world was designed to give the patient the illusion of going inside the 3D computer generated world, where they floated slowly down a computer generated river in VR, with trees, boulders, and mountains. Each patient listened to mindfulness training instructions followed by sounds of birds and crickets chirping, and water sounds, in an immersive computer simulation of floating down a 3-D computer-generated river during the VR DBT  mindfulness intervention (see Figure 1).
Patient 1 listened to Observing and Wise Mind audios while in virtual reality. The patient received "observing visuals" for session 1, "observing sounds" for session 2, and "wise mind" for session 3, and "observing visuals" again, for session 4. While in VR, Patient 2 received "observing visuals," and "observing sound". He only had two sessions of VR because his health improved sufficiently that he was discharged before a third session was implemented (i.e., he did not receive the "wise mind" VR DBT  session).
The current study used a measure designed specifically for medical patients. BDI -FastScreen is a reliable 7-item self-report instrument valuable for measuring the severity of the patient's depression (Beck et al.,). The BDI Fast Screen has been shown to have concurrent and discriminative validity (Benedict et al.,). The BDI Medical Fast Screen is an abbreviated version of the longer Beck Depression Inventory (Beck et al.,). Patients respond to multiple choice questions to measure the severity of the patient's depression. The questions ask patients to rate their hopelessness, irritability, feelings of guilt, etc.
The Spielberger State-Trait Anxiety Inventory (STAI-Y). Internal consistency coefficients range from 0.86 to 0.95, and it has good test-retest reliability coefficients ranging from 0.65 to 0.75 (Spielberger et al.,; Spielberger,). The 10 item "STAI-Y short" used in the current study produced scores similar to those obtained with the full form of the STAI-Y (Bergua et al.,).
Previous VR DBT  studies used diary based measures of negative and positive emotions (Navarro-Haro et al.,; Gomez et al.,). The current study introduces new measures using a Graphic Rating Scales question format (Jensen,). The Graphic Rating Scale is a 10-unit horizontal line labeled with number and word descriptors. Patients can easily answer these GRS ratings despite having no previous experience (Tesler et al.,). Using single GRS questions, patients rated how "depressed" and "nervous/anxious" and how "emotionally upset" they felt before and after each VR session. Before and after each VR DBT  Mindfulness Skills Training session, each patient also briefly rated on a scale from 0 to 10 the intensity of several primary emotions (sadness, fear, anger, guilt, shame, disgust, and joy, see Ekman,; Linehan,; Navarro-Haro et al.,; Gomez et al.,). To measure acute stress disorder/PTSD symptoms, we created a new Graphic Rating Scale of current ASD/PTSD symptoms, adapted from the diagnostic criteria of the DSM-4 (American Psychiatric Association,).