In 2020, the world faced the COVID-19 pandemic, which accelerated the virtualization of many aspects of our lives. The pandemic also impacted mental health negatively; about four in ten adults in the U.S. have reported symptoms of anxiety or depressive disorder compared to one in ten adults who reported these symptoms in 2019 (Panchal, 2021). Additionally, the World Health Organization has reported that one in four people in the world will be affected by a mental or neurological disorder at some point in their lives (Rogers, 2019). The pandemic has forced some people into isolating situations, which may further contribute to their mental stress.
In a time of crisis, it is imperative that people have access to mental health services. Traditional face-to-face therapy may not be possible during a pandemic, due to the increased health risk. This presents a unique opportunity for VR-enhanced therapy, to treat mental health disorders. Research indicates that VR-enabled therapy is an accessible option to treat various mental health disorders. Now more than ever, there is a need for a scalable virtual therapy option, making VR-enabled therapy a promising candidate.
2. What is Virtual Reality
The Merriam-Webster dictionary defines virtual reality (VR) as “an artificial environment which is experienced through sensory stimuli provided by a computer and in which one’s actions partially determine what happens in the environment.” Historically VR use was primarily confined to a laboratory, but new head-mounted displays (HMD) are supported by smartphones, laptops, or desktop computers and can therefore be used in homes (Freeman, 2017). HMD’s display images, one for each eye, forming an overall scene. Each image is computed and rendered separately with a correct perspective from the position of each eye (Freeman, 2017). In other words, when a participant moves their head, the computer updates the imagery at a very fast rate, usually 60 frames per second (Freeman, 2017). This correct positioning of imagery helps create the illusion of a dynamic, 3D environment.
Immersion is often a reflection of a system’s technical capabilities; as technology advances, VR becomes more believable (Freeman, 2017). VR technology has been around since the 1980s, but it hasn’t been adopted on a large scale until now. One of the main reasons is the price; in the 1990s, a full VR headset could cost upwards of $15,000; today, one can be purchased for around $200 (Briggs, n.d). Technological advancement and cost reduction make VR an accessible option for mental health treatment. VR is considered an imaginal technology; what makes its environments so believable is the graphics used to create them.
3. VR as Imaginal Technology
VR is “an advanced imaginal system and experiential form of imagery that is as effective as a reality in inducing cognitive, emotional and behavioral responses”(Ventura, 2017). Traditional mental imagery has been used in psychotherapy, such as Freud’s interpretation of dreams.
Mental imagery is described as perceptual experience in the absence of sensory input, often described as seeing with the “mind’s eyes’ “ (Ventura, 2017). Mental imagery is often used to amplify emotional effects, and it can even hijack attention from the external world, making the internal cognition more believable (Ventura, 2017).
There are two ways a mental image can be created: either from immediate perceptual information, or from previously-stored long-term memories. In either case, the problem with using mental imagery is that mental images remain in our minds for an estimated 250ms (Ventura, 2017). Mental imagery can induce learning, emotional responses, and changes in behavior. The same characteristics can be applied to VR, eliminating the need to use mental imagery, providing the user with direct perceptual information that can also last longer.
Furthermore, VR as an imaginal system allows for the creation of environments that might not be possible in the real world (Ventura, 2017). Through the use of imagery, the user feels present in the virtual environment. However, mental imagery alone is not enough to make the user feel a complete sense of presence. The concept of embodied technology creates a sense of body ownership, as explored below.
4. VR as Embodied Technology
Embodiment is defined as having a body, and it is based on the following three aspects: the sense of self-location, sense of agency, and sense of body ownership. Self-location refers to the volume in space where one feels to be located. Sense of agency refers to having global motor control over one’s body (Ventura, 2017). Lastly, a sense of ownership refers to having a sense of ownership over one’s body. All three aspects are interconnected in inducing a sense of body ownership illusion (Ventura, 2017).
Body ownership illusions (BOI) created through VR systems can be applied to improving mental health by inducing changes in the patient’s internal body representation (Gomez, 2021). BOI is often created using virtual avatars to induce and can create a sense of body ownership over a partial or full virtual body (Gomez, 2021). These avatars are often modeled after the user’s appearance and can get as nuanced as voice resemblance (Gomez, 2021). This idea of embodied technology paved the way for a study conducted by Slater that allowed embodied participants to engage in self-counseling, as examined below.
For the first time in human history, VR technology allows us to watch ourselves from a third-person perspective (Ventura, 2017). An experiment by Grossmann and Kross showed that participants are wiser in solving a problem from a third-person perspective compared to a first-person point of view (Slater, 2019). This observation supports the idea of self-counseling by alternating between two virtual bodies. Self-counseling utilizes two avatars, one based on the user and the other based on a theoretical therapist. The user explains the problem and then transfers to the therapist’s avatar. This allows the user to hear the problem from a third-person perspective, while gaining a new point of view. While in the therapist avatar, the user gives advice and then transfers back to their avatar to hear the advice (Slater, 2019). This back-and-forth conversation is the basis of VR-enabled self-counseling.
To further explain, Osimo introduced the technique of self-counseling by allowing participants to be embodied in scanned copies of themselves and explaining their problems to a virtual representation of Dr. Sigmund Freud. They were then transferred to Freud’s virtual body and gave a response to the problem (Slater, 2019). The study shows “about 80% of the 29 participants reported feeling like they had a different perspective on their problem and that this would result in a change in the way they dealt with it” (Schwab, 2019). In other words, the users could gain insight and perspective on their problems through a third person point of view.
Although the initial cost of developing self-counseling systems can be high, it presents a unique opportunity to offer therapy on a wider scale. It is important to note, self-counseling is not used to treat people facing serious mental health problems. These studies aim to address tribulations of daily life, that may feel serious to the individual but are not life threatening. In other words, self-counseling seeks to increase overall mental well-being and equip the user with problem-solving mechanisms (Schwab, 2019). Treatment of more severe disorders such as anxiety and phobias can more properly be treated through VR-enabled exposure therapy.
6. Exposure Therapy
The American Psychological Association describes exposure therapy as a “psychological treatment developed to help people confront their fears by exposing individuals to the feared objects, activities, or situations.” Traditional exposure therapy is also known as in vivo treatment, meaning the situation is recreated in the real world. The disadvantage of in vivo treatment is patient resistance due to extreme anxiety (Ventura, 2017).
Ventura notes that “VR exposure therapy creates a safe virtual world where the patient can explore and experience “new realities”; this feeling of safety is essential in therapy so that the patient can act without feeling threatened” (2017). VR can help solve this problem by confronting the patient with feared stimuli in a safer environment (Ventura, 2017). For example, it is safer to create a VR situation that induces the fear of heights than actually putting the patient on top of a building.
The advantage of VR is that individuals know it is a virtual environment, but have similar psychological and physiological responses compared to a real-world experience (Freeman, 2017). Freeman explains that “minds and bodies behave as if it is real; hence, people will much more easily face difficult situations in VR than in real life and be able to try out new therapeutic strategies. The learning can then transfer to the real world” (2017). With VR, individuals can enter simulations of difficult situations and learn appropriate responses based on the specific disorder (Freeman, 2017). This ability to mirror real-world experiences makes VR an effective method to administer exposure therapy.
6.1 Anxiety and Phobias
Anxiety disorders affect 40 million people in the U.S, which is 18.1% of the adult population (Rogers, 2019). Anxiety is viewed as a condition where patients worry about something fearful excessively and consistently (Park, 2019). The rationale behind using VR for exposure therapy is to repeatedly confront the patient with the feared stimuli to desensitize them (Ventura, 2017). By facing feared situations, individuals can learn and practice positive behavior or coping mechanisms to reduce anxiety.
Phobias are a type of anxiety disorder where the patient has a persistent fear cued by the presence or anticipation of a specific object or situation (Park, 2019). It is estimated that 19 million Americans suffer from phobias (Rogers, 2019). VR exposure therapy was successful in reducing phobias such as the fear of spiders, social phobias, and flight phobias (Park, 2019). For example, let’s examine how VR might help people overcome the phobia of flying. A study by Botella and colleagues aimed to help participants by presenting three virtual scenarios. In the first scenario, participants were placed in a virtual living room to prepare to fly (Ventura, 2017). They were given tasks such as packing and checking in for their flight. In the second scenario, the participants were at the airport; they listened to boarding announcements and prepared to board. The third scenario simulated the experience of take-off and landing in different weather conditions (Ventura, 2017).
Botella followed up with the participants one year after treatment, and the results supported the efficacy of VR in the treatment of flying phobias. After the treatment, all participants flew in real life (Botella, 2004). Repeated use of VR increases the anxiety threshold, making participants less sensitive to the phobia. As illustrated above, VR can provide a safe, controlled environment for exposure therapy.
Post-traumatic stress disorder (PTSD) is a psychological reaction that occurs after experiencing stress that has caused life-threatening extreme mental trauma. PTSD affects 7.7 million people in the U.S, causing symptoms such as insomnia, anxiety, agitation, and personality changes (Rogers, 2019). People with PTSD often experience flashback-type mental images. These flashbacks often hijack the person’s attention further away from the external world, “making the internal cognitions more believable and associated emotion more powerful” (Ventura, 2017). In other words, flashbacks are powerful mental images that can often change a person’s behavior. VR-enabled therapy focuses on exposing the user to the source of their disorder (Park, 2019). The advantage of using virtual environments means people do not need to imagine their experiences; the work is done for them.
Dr. Rizzo developed a program called Bravemind in collaboration with the U.S. Army for the treatment of PTSD. In this program, patients were virtually sent back to areas of conflict like the Middle East. The soldiers held rifles, and explosions were simulated; even smoke and dust were vented into the treatment room. (Rogers, 2019). Bravemind was deemed a success and helped veterans process their experiences, reduce panic attacks, and even allowed some to sleep without medication for the first time in years. (Rogers, 2019).
The benefit of VR is that it “goes beyond space and time, researchers do not have to wait for specific events to occur. Rather, they can simulate them whenever appropriate for the patient and the therapy process” (Ventura, 2017). To summarize, VR allows the patient to have incremental, controlled, and safe experiences to overcome PTSD. As shown in the examples above, VR is a viable option for treating mental health disorders. However, as VR gains popularity, several ethical and technological limitations that must be resolved.
7. Limitations of VR
VR-enabled therapy is a part of the digital health market, which is expected to be worth over $500 billion by 2025 (Briggs, n.d.). As VR reaches a new height of popularity, responsibility and ethics must be considered. Designers who work on VR technology must design ethics into the process. This calls for more people who genuinely care about people’s well-being, not just the monetization of such services (Briggs, n.d.). As the type of data available grows, so does the concern for anonymous data collection. The data collected through VR goes beyond social media activity and purchase history. VR can produce data that can determine people’s feelings, behaviors, judgements and physical likeness, hence posing a threat for misuse (Briggs, n.d.).
Another challenge is the inherent risk of immersive experiences and their ability to affect the natural world. Nick Yee coined the term “Proteus Effect,” which states that people are affected by their digital representations, and their behavior may change in both the virtual and the real world (Briggs, n.d.). For example, one study found that a taller avatar negotiated more aggressively than subjects embodying a shorter avatar (Briggs, n.d.). The ability to alter people’s perceptions and behaviors can be misused. This poses a risk and the possibility of unpredictable behavior, especially if the creators of these programs fail to do their due diligence. Designers, developers, and mental health professionals need to work in cohesion to create a comprehensive experience focused on the user’s well-being (Briggs, n.d.).
Additionally, if the gap between reality and what life could be like is extended too far, this could affect mental health and result in an addiction of VR technology (Briggs, n.d.). Patients can become addicted to the VR environment or form delusional thinking. This can turn into something intended to help into a determined experience (Briggs, n.a). Lastly, people have reported discomfort when using VR and symptoms such as motion sickness, eye fatigue, headaches, nausea, and sweating (Cieslik, 2020). As VR technology advances possible adverse physiological and psychological effects of using VR should be addressed. Although there are limitations of VR technology, there are clear benefits of using VR-enabled therapy. Therefore, it is worthwhile to find solutions to these challenges.
VR-enabled therapy benefits are being researched at a larger scale, which showcases this technology’s possible efficacy. There is an increased interest in using VR-enabled therapy demonstrated by the number of articles published in the Medline database. Health-related articles with the keyword ‘virtual reality’ doubled in less than a decade, going from 3203 articles in 2010 to 8890 in 2017 (Cieslik, 2020).
VR technology has been successful in treating mental health as a result of its unique ability to create a sense of presence. Using imaginal technology to induce a sense of body ownership allows the user to feel connected to the virtual environment. The concept of VR self-counseling can be utilized to manage the trials of everyday life. Meanwhile, VR-based exposure therapy can be used to treat disorders such as phobias and PTSD. Using VR to administer exposure therapy gives the patient a sense of safety, hence relieving the user of anxieties. VR also enables researchers and mental health professionals to have greater control and precision.
As research continues and technology improves, we look forward to a sense of hope. Hope for a future where mental health services are accessible, affordable, and useful. Perhaps, through design virtual environments can even offer sanctuary. As our world becomes increasingly connected, we must also nurture our connection to self. Creating virtual worlds to promote well-being is not only fascinating but also a noble cause. The use of technology to have a positive impact should be at the forefront of innovation. As we evolve we will face new challenges that can be solved only by working together.
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