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Do you ever have days when you can\u2019t seem to do anything right? Days when you\u2019re fed up with yourself? Days when you berate yourself for things you\u2019ve said or done with the sort of angry monologue that you wouldn\u2019t subject a friend to? From time to time, we all do. But while it\u2019s common to sometimes struggle to be kind to ourselves, for some people, especially those with depression, relentlessly picking at their own worst traits can become an endless cycle of self-bullying.<\/p>\n
Therapy seeks to break that cycle through various approaches and one of the newest involves virtual reality (VR). At University College London, Prof John King and Dr Emma Jayne Kilford are working on a VR intervention to use as an adjunct to face-to-face therapy for depression. They hope the new therapeutic angle VR provides can help people increase their ability for self-compassion.<\/p>\n
Their system uses a virtual room in which there are two avatars: a child and an adult. Before participants enter the room, they\u2019re trained in how to use a compassionate script to lift the mood of someone who\u2019s distressed. There are three parts to the script: validating experience, redirecting attention and activating a positive memory.<\/p>\n
As the participant enters the virtual room they\u2019re confronted with the distressed virtual child and their task is to comfort the child using the script until its distress lessens. The next time the participant enters the room, they\u2019re the child and they get to see their adult avatar (themselves from the previous session) performing the compassionate script. \u201cThey sit there as a child,\u201d explains King, \u201cand they literally have the experience of compassion. It\u2019s a form of very souped-up imagery.\u201d The adult avatar can even be made to look like the participant, although not all of them opt for this.<\/p>\n
Initial results in one sample of self-critical students and another of people experiencing depression show significant reductions in measures of self-criticism and depression, as well as improvements in self-compassion. A larger trial has begun, with hopes that the intervention will become an option for people undergoing treatment for depression.<\/p>\n
This is just one of many VR interventions for mental health problems that are currently in development or already in the clinic. VR in mental health treatment has been around since the mid-1990s, but recent advances in headset capabilities and reductions in cost have made it more feasible and accessible, and research in VR-assisted therapy is booming.<\/p>\n
The most-established use of VR-assisted therapy is for anxiety disorders. For simple phobias where someone has one predominant fear, VR can be used to expose the person to that fear gradually and safely. \u201cI was plagued with a fear of heights for years,\u201d says Judith Keeling, who heard about a research trial into VR therapy for height phobia in her hometown of Oxford and decided to try it. \u201cI was intrigued, but dubious.\u201d<\/p>\n
Judith remembers the experience: \u201cYou put the [headset] on and you find yourself in the atrium of a shopping mall. You can choose what floor you start at, then you go to that floor in a lift. [The doors open, you walk out] and there\u2019s a glass barrier between you and the drop, as if you\u2019re looking down into the atrium. And then the barrier is removed. I jumped back when that happened.\u201d<\/p>\n
Even though Judith knew it wasn\u2019t real and she found the VR setting somewhat cartoony, she still felt as if she was up high. For Daniel Freeman, a professor of clinical psychology at the University of Oxford, that\u2019s no surprise. \u201cWhatever the computer shows you, that\u2019s your reality\u2026 The beautiful bit of the therapy is that there\u2019s also a conscious bit of your brain saying it\u2019s not real, therefore I can try things differently. It doesn\u2019t break the spell; it just enables you to make the learning.\u201d<\/p>\n
In this intervention, people complete increasingly tricky tasks on each floor until they reach the top floor, where there\u2019s a wobbly bridge to walk across, which they can see through. If they accomplish that, they get to ride on the back of a surreal blue whale that\u2019s been floating around inside the shopping mall. \u201cIt feels unreal,\u201d says Judith. \u201cSo although I was uncertain, I could make myself do it.\u201d<\/p>\n
After three sessions Judith wasn\u2019t sure whether the treatment had done much, but she noticed the difference when she went on a once-in-a-lifetime family holiday. \u201cI was at Angkor Wat, in Cambodia, where there are a lot of rickety outdoor ladders and I was walking up and down them without any problems.\u201d<\/p>\n
Freeman sees a key role for VR in automating some aspects of therapy to improve access. \u201cThere are some very powerful psychological therapies, but far too few people get them,\u201d he says. Freeman also thinks VR therapy can be more powerful than traditional therapy. \u201cYou can do things you can\u2019t do in face-to-face therapy\u2026 The ultimate aim is using the tech not just to replicate successful therapies\u2026 but to push them even further.\u201d<\/p>\n
One example of pushing the therapy further is in the treatment of post-traumatic stress disorder (PTSD). PTSD involves a trio of symptoms: hyperarousal (feeling extra anxious to threat), avoidance (not wanting to think or talk about traumatic memories) and re-experiencing symptoms, such as intrusive images, nightmares or flashbacks.<\/p>\n
PTSD is common in war veterans and a VR package called Bravemind has been designed specifically for soldiers who served in Afghanistan by Dr Albert \u2018Skip\u2019 Rizzo at the University of Southern California. \u201cWe use the best technology to train soldiers for war; we should use the best technology to fix the\u2026 mess afterwards,\u201d he says.<\/p>\n
Bravemind simulates war situations using 14 customisable virtual worlds. A therapist controls what happens, tailoring content to the memories of the person reliving the trauma, allowing those memories to be processed and the re-experiencing of symptoms to resolve.<\/p>\n
The principles are identical to traditional cognitive behavioural therapy for PTSD, so the treatment still needs a therapist but the imagery is more immersive. \u201cIt\u2019s a real-time clinical tool,\u201d says Rizzo. \u201cTechnology doesn\u2019t fix anyone; it extends the skills of a well-trained clinician.\u201d When Bravemind is used in conjunction with a trained therapist, its results are equivalent to, or better than, traditional therapy. A small fMRI study showed changes in the brain areas associated with PTSD too.<\/p>\n
It\u2019s not only depression and anxiety that can benefit from VR therapy. At the Institute of Psychiatry, Psychology & Neuroscience (IOPPN) at King\u2019s College London, Dr Lucia Valmaggia and her colleagues are working with individuals who experience psychosis, which is characterised by a loss of contact with reality that often involves hearing or seeing things that others can\u2019t, strong feelings of paranoia or delusional thoughts. VR can simulate situations where paranoia might be problematic.<\/p>\n
\u201cWe use the VR as a first experience of something,\u201d Valmaggia explains. \u201cFor example, someone walks into a VR pub and the first thing they do is tense up when someone says hello. You see if they\u2019re aware or not that they\u2019re doing it. You teach them to breathe, to become aware of their jaw, to do all of that. And then they try it. Not straightaway in a real pub, but in a VR situation around other people.<\/p>\n
\u201cThe person experiencing it knows that it\u2019s not real so they\u2019ll try to do more things and they\u2019re more able to get new experiences and physiologically new responses,\u201d she says. \u201cIt\u2019s a trick to have experimental control in an ecologically valid environment and, at the same time, [for] the person experiencing it to be able to try something new.\u201d<\/p>\n
Jemma* has tried the intervention. Diagnosed with psychosis in 2019, Jemma has a background in video game experience design and her psychotic experiences left her feeling convinced that she was living inside a game. As these beliefs subsided, Jemma found she became uneasy in social situations and was uncomfortable being seen by others.<\/p>\n
\u201cI had a visceral reaction to [the VR therapy]. It was kind of amazing,\u201d says Jemma, who froze as she went into the virtual pub, due to feeling intense fear. \u201cI just totally shut down and couldn\u2019t say anything\u2026 There\u2019s no hiding from it\u2026 It\u2019s very honest and transparent.\u201d<\/p>\n
With practice and therapeutic support, Jemma overcame her fear and became more comfortable and confident. She was also recommended a relaxation programme available on YouTube that lets her swim with dolphins in a virtual sea by using a cardboard VR headset into which she slots her mobile phone. \u201cIt\u2019s very relaxing,\u201d she says.<\/p>\n
VR therapy is not without its challenges. While the headsets are vastly cheaper than they once were, accessibility still depends on clinics being able to purchase them for patient use. There\u2019s also a strong need to understand the ethical complexities around digital security to ensure sensitive data can\u2019t be harvested. \u201cI do see that as being a critical issue,\u201d cautions Kilford. \u201cThe tech always moves so much faster than the regulatory body.\u201d<\/p>\n
The inevitable lag between technological progress and good-quality research means studies can be out of sync with the technology by the time they\u2019re completed. Plus, VR only works for certain types of talking therapy (usually those belonging to cognitive behavioural schools).<\/p>\n
Nevertheless, the tech and research advances mean VR therapy is finally coming of age. Rizzo thinks we\u2019re not far off the day when \u201cheadsets in the home will be like toasters. You know, you don\u2019t use it everyday, but every home has one\u2026 It\u2019ll get to a point where every clinician has a VR headset in their drawer and they\u2019ll have had some training [on how to incorporate its use into therapy] at some point.\u201d Rizzo also thinks 5G will help clinicians access VR interventions.<\/p>\n
The variety of VR-assisted therapies being researched covers a huge range of disorders and settings. There are VR kitchens to help people with eating disorders, relaxation programmes for people in inpatient care, and programmes for schoolchildren to help them handle their assumptions of what others think of them (especially helpful for children who\u2019ve been bullied or had experiences that can affect future relationships). Whatever you can imagine a use of VR for, it can be programmed.<\/p>\n
VR therapy won\u2019t replace human therapists, but it\u2019s a powerful adjunct and access to it is going to grow. VR therapy for fear of heights is already available in a number of UK NHS Improving Access to Psychological Therapy clinics, and several of the VR research trials are available in NHS Trusts too.<\/p>\n
As VR therapy grows, it\u2019ll be key that the programmes we choose are ones with established efficacy, and are co-designed by clinicians and people with experience of mental health problems. And there is no shortage of those to choose from.<\/p>\n
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