Virtual Reality: Expanding the therapeutic toolkit?

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Mental health tech is enjoying something of a resurgence: with innovations like chatbots and AI-driven therapies being touted as “the next big thing”, ready to disrupt a field in dire need of more solutions. But we have seen the promise of technology in this space fall flat before. Health apps were widely thought to have the potential to revolutionise mental self-care, but evidence about their effectiveness continues to be in short supply: when, after years of anticipation, the NHS’ Digital App Library finally launched earlier this year, it contained just one clinically approved app.

One of the technologies presently riding high on the hype cycle is virtual reality (VR). But is VR truly representative of what the next generation of mental health technologies might be capable of? We take a look at some of what VR might offer in a notoriously complex and challenging field.  

VR and Mental Health

Perhaps the best-known application of VR technologies to date has been as so-called ‘empathy machines’ to raise awareness of mental health-related issues: examples include the Guardian’s ‘6×9’, which aims to communicate the psychological impact of solitary confinement, the UN’s ‘Clouds Over Sidra’, created to promote work on building resilience in vulnerable communities, and Francis, a first person account of a teacher in Ghana’s mental health crisis, positioning mental health as a priority in global development.

But possibilities of immersive environments which are created in VR go beyond these kinds of applications. Increasingly, we are seeing potential for its use as a form of treatment in tandem with therapy.

To date, VR has primarily been used to augment ‘exposure therapy’ (where individuals are able to explore painful or fear-inducing situations in a safe environment) in the treatment of a number of conditions. In the treatment of Post traumatic stress disorder (PTSD), VR has made it possible to, for example, recreate war scenes allowing people to gradually revisit traumatic events under the guidance of their therapist; learning to manage or potentially even overcome such experiences over time. Meanwhile, the creation of immersive social environments may help those suffering from schizophrenia, allowing them to gradually engage with environments that they previously feared. Similarly, VR is being used in the treatment of phobias – including simulating flight, for someone with a fear of flying –  while the therapist remains in control of the situation.

Taking a closer look – the AVATAR approach

Beyond these applications, we can gain a better sense of the potential of VR in mental health treatment by exploring the AVATAR approach. Developed by a team initially led by Julian Leff at UCL, involving therapists, linguists and computer scientists, the approach addresses an aspect of psychosis which is notoriously difficult to treat: persecutory voice hearing (hearing persistent and dominant, often abusive, voices). Virtual reality could offer psychiatrists a potentially groundbreaking tool to support them in treating individuals and in gaining a better understanding of the nature of the relationship between individuals and the voices they hear.

Virtual reality could offer psychiatrists a potentially groundbreaking tool to support them in treating individuals

So how does it work? At the start of a course of therapy, patient and therapist work together on building up a digital “avatar”, a virtual representation of the voice, which resembles both its pitch and tone as accurately as possible, and giving it a physical appearance. Therapists can use this avatar to communicate ‘as the voice’ with their patient, who is then encouraged to respond to the avatar – with the aim of re-calibrating the relationship. For those with schizophrenia, for example, voices may have a debilitating impact on those who suffer from them. Tools which empower individuals to better manage this dynamic could have a far-reaching impact, with as many as one in eight people reporting hearing voices (although certainly not all of these auditory hallucinations are negative or severe).

There is a growing evidence base around the AVATAR approach – the results of a pilot study showed a reduction in the dominance and malevolence of perceived voices, and even some cases of them disappearing altogether. The approach has since been taken to a large-scale clinical trial, with results coming soon.

Where next for VR and Mental health?

Many health tech solutions to date have functioned almost as a ‘digital reinterpretation’ of existing treatments and services. Teletherapy or health apps replace physically present therapists, with chatbots mostly functioning as a non-human emergency support line. VR, instead, appears to have the potential to expand the therapeutic toolkit in new directions, allowing us to approach mental health treatment in ways not previously possible.

So what next? We may start to see more instances of the clinical use of VR for a range of conditions such as anxiety, or obsessive compulsive disorder (OCD). Thus far there has been most attention for VR solutions looking to address schizophrenia or paranoia, at the King’s and Oxford VR labs for instance, but there is a growing evidence base for its use with other conditions.

Interdisciplinary collaborations between technologists, therapists and researchers are vital

But there are real obstacles to be overcome: notably, how do we scale up virtual therapies? One option is to explore self-help on the medium. Whilst VR has so far only been used as part of treatment with a therapist, the technology is expected to be owned by 16 million people by 2021 in the UK alone, opening up pathways for self-treatment solutions. There is already some progress here, with the Oxford Virtual Reality for Mental Health having just launched Nowican, a VR programme to guide people through psychological techniques using just a virtual therapist. It is critical that self-treatment options using VR are built on an evidence base in order to avoid the same pitfalls as digital mental health apps.

We are only just beginning to test the potential applications of VR for mental health, but early signals suggest this could be very fertile ground for further research, evaluation and investment. But to design truly useful tools, interdisciplinary collaborations between technologists, therapists and researchers are vital – and the involvement of professionals will be essential in ensuring interventions help, rather than harm vulnerable patients.