Student Choice: Mental VR therapy and the Deep VR

Therapy for anxiety, depression or other mental issues throught VR

Introduction

As we saw in the entire course and especially in our experience in implementing the second project, Virtual Reality (VR) is a technological interface that allows users to live a digital environment within a controlled settings that could show whatever the provider want. For this reason it has been increasingly used in various clinical research fields such as mental health treatment. The primary focus of this sort of article is to review the available literature regarding the effectiveness of VR within psychiatric treatment with a special emphasis on anxiety disorder. Actually, VR is a perfectly well-suited technology for the exposure based treatment for mental issues as it permits to really feel yourself inside the computer-generated environment which shows a feared situation for the user. We will go through potential advantages and disadvantages in using VR within psychiatric research and treatment and we will show a concrete application that exemplifies this kind of technique. In this first part we will analyze the VR mental therapy in general thank to the numerous papers that can be found. One of these is “The use of Virtual Reality technology in the treatment of anxiety and other psychiatric disorders” and can really help us to deeply understand this complex theme.

Why using VR in clinical research?

So, as we said before VR aims to parallel reality and create a new world that is both immersive and interactive. When we use it we really believe that the paradigm accurately simulates the real Reality that it is supposed to be recreated. As we saw in class, this result is due to the use of technology like for instance head-mounted displays (or glasses), gesture-sensing gloves, synthetized sounds and vibrotactile platforms, which allow to accurately simulate all our senses. Furthermore, some VR paradigms react to the actions of the user increasing the realism of the environment itself. In all, VR is potentially a powerful tool for the psychiatric community because the user experience can be consistently replicated, tested, and modified within a safe environment without compromising real-world applicability. VR’s precise control of sensory cues, particularly for auditory, tactile, and olfactory systems, increases the sense of realism and memory of the virtual environment.

In the last years, many researchers agree in considering exposure-based therapy for anxiety disorders as a good technique with significantly large treatment effects. The main concept behind it is the emotional processing theory which states that fear memories are structures that contain information regarding fear stimuli, responses and meaning. Thus, the purpose of the intervention is to activate and modify these fear structures embodied in the memory through new incompatible information and assisting the patient’s emotional processing. In this kind of context, the VR is perfect for the exposure therapy, actually the sense of presence experienced in the digital environment created in VR allows to immerse the user in the feared situation that is shaped for the specific aspects of their fear structures to activate and modify them. There are a lot of interesting results that prove that VR treatment research conducted for anxiety disorders make large declines in anxiety symptoms with similar effects compared to traditional exposure techniques and with good stability of results over time.

There is evidence that treatment gains made in VRE generalize to real life, as meta-analytic results suggest that VRE patients, compared to wait-list patients, perform significantly better on behavioral assessments post-treatment, and found no significant differences between VRE and in-vivo exposure at post-treatment and follow up.

Advantages and Disadvantages

The main issue in traditional therapy is that imaginal exposures are obviously based on patient’s capability to imagine effectively particular feared stimuli. VR solves perfectly this kind of problem, creating an accurate environment which reproduces the feared situation in a pretty realistic way. More other, in vivo-exposures can be expensive (like an actual flying) or impossible to experience (a combat in war), while VR, without considering the initial cost of the tools, is absolutely inexpensive and allow to recreate environments that may be difficult to implement in-vivo. The manipulation allowed by VRE is incredible giving the possibility for example to repeat a virtual flight landing multiple times. In addition to this, another important advantage of using VR in the treatment is the complete control on the experience as the it is possible to select the dose and the specific aspects of the exposure environment according to the particular feared stimuli of the user making the experience highly personal and individualized. For instance if a patient with the fear of flying is not ready for the turbulence the therapist can guarantee no turbulence. Thus during exposure the confidentiality of the patient will surely remain intact while in-vivo it is not always possible.

So as we can see, there are several advantages in using Virtual Reality in psychiatric research especially because of the opportunity to conduct exquisitely controlled clinical and experimental research. For example, in the first human study examining the efficacy of combining D-cycloserine with exposure therapy, each research participant received exactly the same exposure to virtual heights. Another useful pro is the opportunity to collect several relevant data t treatment through VR, such as psychophysiological assessment and data specific to the exposure (stimuli used, time in exposure,…). For instance , for VR approaches with substance use disorders, the exact timing of craving and decision to use can be monitored in a VR environment. Additionally, testing of a skill or medication designed to reduce cravings can be tested in a VR environment rather than in the more dangerous “real world”.

Now let’s analyze on the other hand some of the disadvantages to consider in the use of VR. In the past, the main problems that prevent VR becoming so used in this kind of field research were the quality of the technology and the costs. It was very expensive, difficult to set up and there were a lot of problems in running applications. Even today the costs to begin Virtual Reality are pretty high but prices have decreased a lot and now there are some smartphone-based VR therapy systems within reach of middle class too. In parallel, also the quality of the technology is improving with less likelihood of malfunctions and more other the application are more easily usable by all, but some times there would be “glithces” that is not a good thing in clinical interventions. In addition to this, another possible con in using VR is the need for a specific and tough training and practice before the clinical use, to ensure the ability to effectively trouble-shoot glitches while still maintaining competent clinical care.

The Treatment

VRE typically begins with 2–3 initial sessions in which psychoeducation regarding the specific disorder, psychosocial history, an overview of avoidance and the rationale for exposures, and the process of VR based exposures is discussed. Usually treatments include some exercises for relaxation before the effective intervention, like breathing relaxation (basically yoga exercises) or cognitive restructuring. It is also typical to adopt a sort of graded hierarchical exposure in order to introduce the patient step by step inside the VR feared environment, making him progress and customizing the digital world more and more

Quality VRE is individualized to the patient. For instance, each step on the hierarchy can be repeated until the patient’s anxiety decreases significantly, as noted by their subjective units of distress ratings and therapist’s behavioral observation. The progresses of the patient are slavishly followed by the therapist who talks with him before every level up in the graded exposure. The content available for a fear hierarchy are often preselected for VR exposures, as specific VR system content is developed for specific disorders and specific traumatic experiences or fears. Obviously the therapist has to deeply analyze the patient’s fear or specific traumatic experience before the actual exposure in order to understand how they progress through the various step of the treatment and the time to be spent with each problem. For instance, the fear of flying hierarchy includes eight steps, from walking through an airport terminal to flying during a thunderstorm with turbulence. Every mental issue has its own main focus to take into account: for instance a patient with panic and agoraphobia has to receive specific stimuli linked to these symptoms (the sound of a huge people crowd), whereas for a patient with specific phobia of flying due to an underlying fear of the plane crashing, flying through a thunderstorm and turbulence may be an important focus. For patients with PTSD, a thorough assessment of the patient’s index trauma will facilitate the therapist being able to prepare in advance what VR program to utilize (e.g., Virtual Iraq) and the specific setting and stimuli (e.g., time of day, specific weapon noises) that may be used.

One of the most important thing in order to have optimal results in VR exposure is to have skillful therapist who know how to engage the patient and activate the fear structure. They have to be conscious of encouraging and emotional engagement during the VR experience and they must aware the user for the prevention of any safety behaviors as necessary. In fact, patients may try to engage in safety behaviors, distraction or active coping strategies within the VR environment and so the therapist should make the patient to emotionally engage during the exposure avoiding this kind of behaviors that could make the treatment inefficient.

VR is incorporated at the point in treatment when in vivo exposure would normally be administered. As an example, a typical protocol using VR for fear of flying teaches anxiety management techniques in the first four sessions and incorporates VR exposure to a virtual airport and airplane in the last four sessions. Specific equipment and training is needed to integrate VR into psychiatric practice effectively. A VR system will typically consist of a computer with two monitors, one for the provider’s interface in which they are constructing the exposure in real time, and another for the provider’s view of the patient’s position in the VR environment, and a head-mounted displays and a platform.

Integrating VR in psychiatric care

VR is incorporated at the point in treatment when in vivo exposure would normally be administered. As an example, a typical protocol using VR for fear of flying teaches anxiety management techniques in the first four sessions and incorporates VR exposure to a virtual airport and airplane in the last four sessions. Specific equipment and training is needed to integrate VR into psychiatric practice effectively. A VR system will typically consist of a computer with two monitors, one for the provider’s interface in which they are constructing the exposure in real time, and another for the provider’s view of the patient’s position in the VR environment, and a head-mounted displays and a platform.

Another think to take carefully into account when we want to integrate VR into psychiatric practice is the training. There are plenty of training courses on internet for the VR therapy as well as on-site. Providers must be really prepared in using the VR technology before making the patients use it. Training for providers should include information and practice of trouble-shooting for glitches within session, as well as possible contact information for individuals from the VR vendor who may be able to help trouble-shoot. Obviously, providers should be well prepared about the reasons for using VR within psychiatric treatments to communicate to the patients with credibility. So the VR training is really a fundamental prerequisite for the therapist: a bad VR therapy is still just bad therapy.

What about the future?

According to the paper, "Future research could identify factors relevant to who may or may not be a good candidate for VR-based treatment. Individual differences related to immersion or sense of presence may be relevant. More broadly, research focused on the therapeutic process within VR and not just outcome will be important.106 Research testing hypothesized mediators and moderators of VR-based treatment will prove informative, for example, investigating factors such as emotional processing, psychophysiological markers during exposure, and the therapeutic alliance.""

Anyway the VR-based treatment and clinical research will be more and more important in the next few years. The potentiality of this applications are really huge and it allows to perfectly exploit the immersive power of Virtual Reality in a very useful field. The only problem that we have to take into account is surely the excessive use of this technology on patients, especially considering the feasible improvement in the quality of the realistic environment recreation. Actually, the purpose of the whole work is not to escape from the problems of the Real World sheltering in safe fake place but to face them tanks to a sort of training in the Virtual Reality. Thus thinking about the future in general in the use of VR we have to pay attention to that: the digital environment is something that could help us to understand and, in this case, to solve our problems in the Real Reality, not to entirely substitute it. In any case, this is a possible ethical issue of the future that it is not already feasible to face considering the sate of the art of the VR technology.

Deep VR

One of the most interesting application which shows us the huge potentiality of VR in psychiatric research and treatment is surely the Deep VR. The Deep VR is at the end a sort of meditative virtual reality game, simulating a beautiful, serene underwater world that responds to your stress with peaceful resonance and gently guides you to take those desperately-needed deep breaths. Actually, the main concept behind this innovative platform is the idea of breathing exercises and what concerned to yoga as well. Actually in this game, the controller is your own breath and the environment dynamically respond to it making you relax and distress. With each inhale you go up and exhaling you go down in a very calmful way. Furthermore, the deeper your breaths, the further you are propelled in this amazing underwater world. All the details are meticulously studied in order to reach the big deal of this platform: alleviate stress, anxiety and mild depression. Indeed, the shapes and the colors of the various are designed following the main psychiatric research schools of thought. Maybe you won’t consciously notice them running the game but the effect on your mind it will be absolutely effective.

The immersive characteristic of the Virtual Reality it is perfect for this kind of objective. You can really feel yourself inside this gorgeous seascape and you can really experience this peaceful voyage for your mind. Thanks to the depth of the realism of the application itself, the effect on the brain is sensible and the results are incredible. Furthermore, there are some sensors added to your body in order to register data about your breath, sending them to the application that has to react to it. This is the center of the platform: through this continuous interaction between user’s breath and the environment the result are pretty good. The anxiety decreases significantly since the first experiences of the application and you feel pretty relaxed benefiting from the yoga technique through an amazing VR game built for you.

The Game experience

There are many reviews about this astonishing application that helps us to deeply understand the experience of the Deep VR, like for example the one of the journalist Joseph Volpe for the Engadget website. Quoting his exact word describing the VR game (which unfortunately I have never had the possibility to try in my life): “Guided by a circular reticle that expanded and contracted along with the movements of my diaphragm, I floated gracefully through a Tron-like underwater world shaded by cool blues, cheerful pinks and relaxing purples as low-poly models of marine life swam about. It took only about 10 seconds or so for the game's breathing-based control scheme to become intuitive, at which point I'd become so engrossed in gliding through the environment and surrendering my mental state to the fuzzy murmur of binaural beats sound tracking it, that I'd forgotten about Tribeca and the media frenzy around me.”

The purpose of Deep VR

"We want to help teach people these breathing techniques so that they can then manage these conditions outside of the game," says Harris of Deep VR's intended stress- and anxiety-reducing goal. "This is a technology that exists within all of our bodies that costs no money [and] that we have all have access to." And that is the real point of the Deep VR: a free technology devoted to helping people to go through their fears and their mental weaknesses of the Real Reality thanks to the use of a secure and relaxing digital environment created ad hoc for the human mind.

Now Deep VR it is not only a calming escape for VR enthusiasts but a real basis for a psychological study that aims to alleviate anxiety in children. Actually the research and development-based process will move forward in two phases: the modeling and the exposure therapy. The first consists in using some design details of the environment in order to help users in deep-breathing technique through imitation, not with any specific verbal direction by the therapist. There will be the possibility to see animals for the viewers to follow that ascend and descend in accordance with how we have to breath and with which rate. The second part of the study we have presented earlier and it is about experiencing real fears of the Real World in the VR environment in order to know to manage them. This addition will shift the overall tone of the Deep VR from sedative to mildly and purposefully frightening. "When people are anxious, what you do is systematically desensitize them," says Isabela Granic. a professor of Behavioral Studies at Radboud University in the Netherlands partner of Harris "You bring them closer to the things they fear while they are being taught these deep-breathing relaxation techniques."

Conclusion

Thus, we deeply understand the potentiality of this innovative way to approach mental health and even now the results are incredible. In the future, the two designer of the application, Harris and Smit, want to make the game’s soundscape more interactive so specific environments corresponds to specific brainwave frequencies and ambient music. They also hope to get an affordable, consumer-ready sensor design that can be used as a controller for a variety of games. Anyway I think that it will be very useful in the clinical research within mental health and the more the VR will become powerful and precise the more the Deep VR will be efficient in helping people facing their own mental issues, whatever they are.

References:

  • VR therapy Image
  • Deep VR Image
  • Deep VR environment image
  • Deep VR website
  • Yourtunrn blog
  • Engadget
  • Paper
  • Center for anxiety
  • You tube video 1
  • You tube video 2