How virtual reality therapy is shaping mental health

VR can be defined as a “computer-generated three-dimensional (3D) simulation, such as a set of images and sounds of real-life situations, with which one can interact in a seemingly realistic way by using special electronic equipment.”¹ With simply an off-the-shelf VR headset (developed for use in video games) and software that creates a virtual environment, psychologists can use VR to assess or treat patients.

For mental health assessment, says Lucia Valmaggia, professor of clinical psychology at the Orygen Digital XR Innovation Lab at the University of Melbourne, “you might want to see how somebody feels or behaves in a certain situation.” As an example, she mentions creating a scenario in which a patient shops for groceries. The therapist can see in real time which triggers disturb a patient; this can help in prescribing appropriate treatment.

In assessment or treatment, “virtual reality is a really good enhancement tool, but it’s not a replacement,” for the therapist, says Kim Bullock, founder and director of Stanford’s Neurobehavioral Clinic and Virtual Reality & Immersive Technology Clinic and laboratory. VR “is used interactively with a therapist as a patient’s guide and coach.” However, VR therapists are being rolled out in some situations.

The virtual experience

As a scene unfolds in VR, the image does not always look real, which leaves a patient in no doubt that the images are generated by a computer. Surprisingly, that does not matter. “When there’s emotion or fear involved, your brain doesn’t require a completely realistic setting for something to be, for example, frightening,” Bullock explains. In some cases, it helps a patient to know that the simulation is not real, says Freeman. “The beauty is that the conscious awareness of these simulations allows people to try things that they would be wary of in real life, but the learning leads to major benefits in day-to-day life,” he says. VR works because it “gets to the heart of successful treatment: helping people make direct learning of better ways to think, feel, and behave,” says Freeman.

As in any healthcare treatment, however, the details matter. “VR is extremely powerful when the content is right, but get the content wrong and it will be ineffective and underwhelming,” Freeman says. “To separate the wheat from the chaff, it is crucial that each VR treatment is tested in a rigorous clinical trial.”

As one example, Freeman and his colleagues are running the Phoenix VR self-confidence therapy trial². This clinical trial was designed to help young people with non-affective psychosis increase their psychological wellbeing and self-esteem by improving positive self-beliefs. “Phoenix provides direct experiences of achievement, coping, enjoyment and relaxation that are used to spark such activities in the real world,” says Freeman. Participants used Phoenix at home and were offered weekly meetings with a psychologist. VR scenarios included tending a virtual community garden, speaking to a camera in a virtual TV studio, or playing games at the edge of a forest, near a lake. Participants reported an increase in positive self-beliefs after the small, 6-week trial³, with recruitment for a larger trial now underway.

Virtual therapists

In some ways, applying VR to mental health is easy, as a therapist can purchase a VR headset, such as the Meta Quest 2, for less than €250. However, developing virtual scenarios is much more difficult and usually requires hiring a programmer to create the needed software. “There [are] very few systems that are really set up for therapists,” says Bullock. “What we’re using is very limited as far as content, and that’s one of the barriers right now.” For example, if a therapist wants to create a specific scenario, it will usually need to be custom programmed.

Uptake of VR has been low, with few psychologists trying the technology. For example, in Bullock’s department of approximately 500 clinicians, only about 5 of them use VR to treat patients. Lack of training in VR hinders wider adoption by psychologists, she says.

VR can help with one of the biggest challenges facing mental health care: a lack of therapists. In the United States alone, 122 million Americans (more than one third of the country’s population) live in areas that lack sufficient mental health resources to meet demand, according to the US Health Resources and Services Administration⁴. Similar shortages exist around the world. As Freeman says, “There are too few skilled therapists delivering the best treatments to meet the high demand, meaning that millions of people are left waiting for the right help.” He believes that VR can solve that shortage.

“Standalone VR treatment does not need a therapist,” says Freeman, as shown by the rollout of gameChange, a VR-based cognitive therapy that has been approved for use in the UK’s National Health Service⁵. The VR tool, which is marketed as a CE-marked class 1 active medical device, allows participants to experience six scenarios: a café, a general practice waiting room, a pub, a bus, a street, or a small local shop. “A virtual therapist voiced by a real person guides the patient, helping them practice techniques to overcome difficulties,” Freeman says.

GameChange is a VR-based cognitive therapy approved for use in the UK’s National Health Service.

The therapy, which uses a virtual coach, is designed to help patients with psychosis re-engage with outdoor activities, such as cleaning graffiti from a wall.