You slowly creep towards the door while being acutely aware that the slightest sound will get you caught. As you reach for the handle and steadily open the large wooden door you hear a slight creak. Suddenly, the expansive and exposed wall to your right explodes in a flurry of shrapnel, wallpaper and dust. A figure starts to emerge from the wound in the wall and stares directly at you with a terrifying smile. You’ve been found out…
Virtual reality isn’t always quite so terrifying but the above example reminds us that the virtual world has the capacity to make us believe what is thrust directly in front of us. The fear is real and the experience is one which mimics the experience of navigating a trap ridden residence. Besides terrifying us and fuelling visions of humanity being locked in a virtual world to escape the real one, what is the future of virtual reality? Well, one emerging area appears to be concerned with improving mental health.
Use of virtual reality to treat mental health difficulties
Psychosis, a cardinal symptom of schizophrenia, is the presence of delusions and hallucinations which can cause considerable distress. Delusions can take many forms and the nature of these seem to be tied to the diagnosis present (e.g. bipolar disorder, depression or schizophrenia). One delusion common to those diagnosed with schizophrenia is paranoia which can, understandably, cause significant distress and impairment in an individual’s life. However, what if we could challenge the paranoid thoughts of those experiencing psychosis and illustrate their unfounded nature? A real-world setting is likely to be too anxiety-provoking for obvious reasons but what if we could recreate paranoia-inducing environments in the relative safety of virtual reality?
This is exactly what a group at the University of Oxford led by Professor Daniel Freeman has explored in their study for the British Journal of Psychiatry last year. They exposed individuals with persecutory delusions (e.g. paranoid thoughts) to one of two mock real-life setting through virtual reality and asked them to do one of two things. One group was simply exposed to the virtual environment and asked to simply experience the situation. The effect of this on their their paranoia was assessed. The second group, by contrast, was asked to drop their guard, stop using their safety behaviours, and actively put their paranoid thoughts to the test (e.g. Do people in this environment see me as an easy target and do they actually do things to belittle me?). This second condition was known as the cognitive therapy group as they were encouraged to actively re-evaluate their delusions in the safe confines of the virtual environment.
There were 30 participants tested and they were randomised to either an exposure or cognitive therapy condition. They were tested in a real-life setting initially, then gradually introduced to the virtual reality environment, and then finally tested in the real life setting once again. At each point participants were tested before and after their immersion to either real-life or virtual reality on a scale assessing the conviction and distress of paranoid thoughts. As a test of ‘credibility’ the participants were also asked whether they believed the virtual reality setting would help them overcome their paranoid thoughts. Participants were tested in one of two different virtual reality settings. The first setting was a typical one for any Londoner: a tube journey. The second was a lift which the participant walked into and could inspect the other passengers.
So, what did they find? They found that there was a significant and large reduction in conviction and distress of delusions following the cognitive therapy group’s immersion into the virtual environments. Interestingly, these findings also carried over to the real-world setting. On average, they found a reduction in scores of around 20% for the cognitive therapy vs the exposure virtual reality condition. This suggested that getting individuals with paranoid delusions to test out their threat beliefs in a safe environment had the impact of reducing their paranoia. This should be considered in light of the difficulty to achieve this in a real life setting due to considerable anxiety and stress. This suggests that virtual reality is a simple and effective way to combat threat beliefs in paranoia.
However, this was only completed over a single day and the long-term impacts of using virtual reality is this way are currently unknown. Is there a dose-dependent effect of VR on threat beliefs? How long do the therapeutic gains last for? Are there individuals for whom this works better or worse? Are there any unintended side effects of using VR for multiple sessions in a patient population? And many other questions which remain to be answered. Psychosis is not the only field where virtual reality has started to prove its worth in treatment and research but anxiety, depression and eating disorders are also highlighted in the recent review by Professor Freeman earlier this year.
It should be noted that virtual reality is by no means only being realised within mental health but it is starting to be used extensively within physical healthcare too. VR provides an optimal way to train new surgeons, doctors, and nurses in medical procedures. This is what current research is exploring and virtual reality is only one avenue. Augmented reality is becoming more common and apps such as VR in the OR allow us to witness surgical procedures in an interactive manner from the comfort of your own home.
Basic Science and Mechanisms Research
So, there appears to be promise for using virtual reality as a way to deliver therapy but what about research more basic, mechanistic, research (e.g. what causes paranoid thinking in the first place)? Surely if we can create a convincing setting then we could start to study how threat beliefs are generated, in the case of psychosis, or understand what might reduce of exacerbate mental health difficulties in general. In an earlier study conducted in 2003, Prof. Freeman showed that paranoid thoughts could be seen in a virtual reality setting with healthy individuals. In their early foray into the use of VR they found that a small number of participants in their sample attributed hostility towards the avatars present in the environment. The researchers argued that this showed that VR could be used to study paranoia and provide a more realistic environment to test predictors of paranoia in a social setting.
Finally, because we can treat these virtual realities as realistic and convincing, they provide a great landscape in which to explore situations which might prove difficult for those at risk for certain mental illnesses. This allows researchers to test out hypotheses without unnecessarily exposing participants to a threatening situation, and with the ease of removing the headset instantly if the situation becomes distressing. For example, it would be possible to further probe the effect of sleep on mood and how this might contribute to mental health difficulties through the use of virtual reality. Now, as with any science, the worth of the study is not dependent on how flashy the toys are which are used but the strength of the research question and design. Although VR may strike some as flashy, it is useful in that it provides a way to recreate reality but in the controlled and safe confines of the lab. VR may currently be synonymous with jump scares and large price tags it is also being used to improve the health of the public. The widespread use of VR across healthcare settings is still a while off. For now, we shall just have to be content with scaring ourselves senseless with Resident Evil and other horror games.
Freeman, D., Bradley, J., Antley, A., Bourke, E., DeWeever, N., Evans, N., … & Slater, M. (2016). Virtual reality in the treatment of persecutory delusions: randomised controlled experimental study testing how to reduce delusional conviction. The British Journal of Psychiatry, 209 (1), 62-67.
Freeman, D., Reeve, S., Robinson, A., Ehlers, A., Clark, D., Spanlang, B., & Slater, M. (2017). Virtual reality in the assessment, understanding, and treatment of mental health disorders. Psychological Medicine, 1-8.
Virtual Reality (Header)