Inside the Effort to Expand Virtual Reality Treatments for Mental Health

A June 21, 1995, headline on page 11 of the New York Times read: “‘Virtual Reality’ Conquers Fear of Heights.” The article told the story of Chris Klock, a junior at Georgia Tech, who donned a head-mounted display once a week for seven weeks, and was transported to a 3-D environment simulating various altitudes. He stared down from a 20-story balcony, traversed narrow bridges suspended above water, and ascended 49 floors in a glass elevator—all without leaving the therapy room run by clinical psychologist Barbara Rothbaum. Klock was one of 17 students to complete Rothbaum’s experiment, which was the first controlled study using virtual reality (VR) to treat a psychological disorder. The study was published in the American Journal of Psychiatry, and the researchers found that those treated with VR reported reduced anxiety and avoidance of heights. Post-treatment, Klock was able to ride a real glass elevator to the restaurant atop Atlanta’s Westin Peachtree Plaza, rather than trudging up 72 flights of stairs.

“Our phones were ringing off the hook,” recalls Rothbaum, now the director of the Trauma and Anxiety Recovery Program at Emory University School of Medicine and the Emory Healthcare Veterans Program. The study, she explains, “presented VR in a whole new light.”

The term “virtual reality” had been coined less than a decade prior in 1987 by computer scientist Jaron Lanier—although cinematographer Morton Heilig built the first immersive virtual experience, known as the "Sensorama,” back in 1960. At the time of Rothbaum’s study, the nascent technology was still primarily considered entertainment, and so the notion that it could have clinical utility was unexpected.

Rothbaum and her collaborator, computer scientist Larry Hodges, were set on devising a virtual alternative to traditional exposure therapy, in which therapists help patients confront anxiety-inducing stimuli in real life or by simply visualizing triggers. Using VR meant that Rothbaum didn’t have to rely on her patients’ imaginations, or physically take them to the highest heights to face their phobias. She could also precisely control the environment and grade the exposure. For example, when she is treating someone for a fear of flying, she can determine when and if to introduce turbulence. And, her patient can take off and land as many times as needed during their hour-long session.

In the several decades since Rothbaum’s first experiment, medical professionals have primarily used VR to treat anxiety disorders, but they have also applied the technology to depression, addiction, pain, ADHD, autism, Alzheimer’s disease, traumatic brain injury, stroke and more. As VR continues to become more sophisticated and affordable, it has transitioned from an expensive toy to a multifaceted technology with the potential to improve patient care. However, as encouraging as the growing body of clinical evidence is, VR still faces barriers to widespread implementation, as well as lingering ethical concerns about personal data sharing. While researchers work to address these remaining issues, many predict VR treatments will soon become available to anyone who needs help—whether or not a patient has access to a real-life therapist.

Broadly speaking, virtual realities are interactive, 3-D computer-generated environments. Some VR is “non-immersive”—that is, delivered on a phone, computer or television, and akin to playing a modern video game. Other VR experiences, like those Rothbaum employs and the examples covered in this article, are “immersive.” They involve some combination of head-mounted displays, sensors for tracking the user’s position and eye movement, and multi-sensory feedback systems like haptic gloves and scent delivery devices, which create the illusion of interacting with the virtual space.

According to Rothbaum, it typically takes about 20 years for technology to transition from academia to society. Computer scientists and medical professionals like Rothbaum must work together to create virtual scenarios that can be applied to clinical settings. Then, the researchers must test these reconstructions with patients, and demonstrate their efficacy and reproducibility in peer-reviewed journals. It’s now been nearly 30 years since Rothbaum demonstrated that VR could be used to attenuate fear of heights, but, she says, “I still don't think it's completely commonplace; I still think that there are some barriers.”

Even once a VR treatment has been rigorously tested, it’s often difficult to disseminate widely. Daniel Freeman, a clinical psychologist at the University of Oxford, says one barrier to implementation is that VR is often used as an aid for therapists, rather than a standalone treatment, and there are too few skilled therapists to meet the high treatment demands. Many patients may also be unable to physically attend therapy sessions due to rigid work schedules or lack of transportation, and others are firmly against attending “traditional” therapy altogether because they fear stigmatization. VR could break down those barriers to care and more.

To reach those without access to a highly trained therapist, Freeman is building high-quality, automated VR therapies featuring computer-generated avatar guides, so a real-life therapist doesn’t need to be present at all times. Last month, his team debuted their newest automated VR cognitive therapy, known as gameChange. The program is designed to attenuate the agoraphobia, or fear of entering spaces from which escape might be difficult, that individuals with schizophrenia often feel. Approximately six times over the course of six weeks, participants met with a virtual coach inside their head-mounted displays, who guided them through everyday scenes that would be too scary to navigate in real life—whether that be a cafe, local shop, pub, bus, doctor’s office waiting room or simply opening the front door to face the outside world.

There will always be sensitive cases where a real-life expert must parse the underlying causes of an issue and devise the best treatment plan, Freeman says. But VR treatments like gameChange, combined with the arrival of affordable and easy-to-use VR equipment, have the potential to grant millions of people access to the help they need. “If we can actually automate and get it to people, then that's really solving one of the huge issues in mental health.”

Clip From gameChange

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With 346 participants, Freeman’s gameChange study was the largest test to date of any VR treatment for a mental health condition. The researchers found that their approach reduced the anxiety and distress caused by everyday situations, and the automated VR therapy was particularly effective at helping those with severe agoraphobia.

Early clinical VR trials often consisted of a single case study or a small patient cohort, and many lacked the rigorous experimental designs expected today. As experimental quality and sample sizes continue to improve, VR experiments are producing equivalent clinical outcomes to traditional evidence-based interventions such as real life exposure therapy, and outperforming them in certain applications. Experts maintain that clinical VR doesn’t necessarily need to best other treatment options if it breaks down the barriers to care that Freeman and others are working so hard to overcome.

“I've stopped looking at it so much like a horse race,” says Albert “Skip” Rizzo, director of medical virtual reality at the University of Southern California’s Institute for Creative Technologies. “We're not out to replace everything everybody has done in the past. But we have an option here that I think is evidence-based, and—for some people—may be better or may be more preferred.”

Much like Freeman and his gameChange project, Rizzo is also fabricating virtual humans—but rather than building avatar therapists, he’s designing virtual patients to train clinicians, among other applications. He has no ethical qualms about treatment protocols like Freeman’s that utilize avatar guides, as long as individuals with serious mental health conditions are still diagnosed and monitored to some extent by a real-life health professional. Virtual human support agents can amplify the positive impacts of therapy, and extend the skills of responsible clinicians, rather than fully replacing them. The technology isn’t there yet anyways, he says, “but we can fill in gaps—we can help people understand themselves better.”

While VR experiences can make some patients nauseous, according to Rizzo data sharing is a larger concern. Even as new technologies offer opportunities to improve mental health treatments, they can sometimes give tech companies a chance to collect personal information. For example, the Oculus Quest 1 and 2 require users to sign in with a Facebook account, thus tracking their gaming habits and potentially even their movement patterns.

Beyond ensuring patient privacy, he’d also like to see a unified platform to deliver a wide range of clinical content all in one place, such as a medical grade, high-security headset that integrates software packages to treat multiple mental health conditions.

Rizzo has dedicated much of his career to developing a VR approach to treat veterans suffering from another common form of anxiety: post-traumatic stress disorder (PTSD). In 2004, he teamed up with Rothbaum to create a virtual Iraq and Afghanistan—replete with Middle Eastern cites, roadways, mountains, deserts and more. The goal was to mimic veterans’ wartime experiences, in order to help them confront and re-process those traumatic events. Clinicians could fine tune the content of these virtual scenarios by controlling the time of day, number of people, ambient sounds, and more—going beyond what patients could accurately conjure in their imaginations during traditional exposure therapy.

Virtual Iraq Afghanistan Next Gen Exposure Therapy Early Glimpse

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With support from the U.S. Army, in 2011 Rizzo upgraded the system to its current version, known as BRAVEMIND, which continues to receive regular updates. Since then, he’s adapted the technology to ameliorate PTSD in victims of sexual trauma, and is working to extend the system to address the various mental health needs of firefighters, law enforcement and frontline healthcare workers grappling with the Covid-19 crisis. He’s also adjusting the BRAVEMIND system to diagnose PTSD, and even prevent it in the first place.

Today, the United States Department of Veterans Affairs (VA) has implemented BRAVEMIND in 15 of the 137 VA medical centers across the country that are treating veterans with VR. Anne Lord Bailey, co-leader of the Veterans Health Administration’s Extended Reality Network, says she receives daily emails from prospective patients requesting VR treatment. “Veterans really look forward to it,” she says.

A pharmacy practitioner by training, Bailey explains that—much like taking a medication—each patient will require slightly different “prescriptions” of VR platforms, experiences and dosing. Healthcare providers are just beginning to gather information about how best to tailor VR treatments to fit the patient and the diagnosis, and it could take years to fully understand the long-term impacts.

Although VR treatments are now relatively common across the VA healthcare system, this leap from lab to clinic is still relatively recent, and generally relegated to large hospital networks and specialized treatment centers. Caitlin Rawlins, Bailey’s colleague and co-leader of the Extended Reality Network, has watched clinical VR gradually become more widespread. Rawlins began investigating VR in 2017 as an alternative to opioids. She wanted to see whether the technology could distract from and reduce post-operative pain and anxiety, by introducing patients to interactive environments where they could paint, play games and participate in guided meditations against serene backdrops. Although her work and other peer-reviewed studies offered promising results, she says it took several more years for the technology to permeate the VA’s healthcare system. Now, the VA Medical Center in Asheville, North Carolina, where she previously worked as a registered nurse, has over 60 VR headsets to treat anxiety, substance use disorders and a myriad of other mental health conditions in addition to pain management and rehabilitation.

Deborah Judge, a veteran of the U.S. Air Force, has been receiving VR treatments for chronic pain at her local VA medical center for over a year. In 2001, she was hit by a drunk driver and underwent numerous surgeries, leaving her with a rare and painful spinal cord disorder as well as short gut syndrome. She was skeptical when her doctor first suggested VR, but once the awkwardness of learning the new technology dissipated she began to enjoy herself. Besides alleviating her back pain and decreasing her reliance on medication, VR has also helped her feel less isolated, and break the cycle of anxiety caused by her PTSD. She can play games, cook virtual food, watch movies and concerts, among other activities. Now, she uses VR for six to eight hours straight during her scheduled hospital treatments, and even bought her own VR headset and hand controls that she uses at home.

Over the years, she’s tried physical and occupational therapy, various medications, acupuncture and more, but she says VR has been the most effective solution thus far. And, because her system is portable, she can play it almost anywhere at any time, including long drives to the hospital in the passenger’s seat. Her only complaint is that the headsets can become heavy and uncomfortable over long periods of time. But, she says, that’s nothing compared to the pain she’d feel without the welcome distraction.

“In a few minutes, I'm in whatever world I want to be in—which sounds crazy, but it allows me to escape from the realities of my everyday life,” she says. “And that, to me, is worth everything.”