Feature

A man steps up to the podium before a crowded auditorium. His hands are clammy and his throat feels dry. He glances at his laptop, reviewing the first slide of his presentation before taking a deep breath and starting his speech.

The experience is going well—so well, in fact, that the man's psychologist,

Sean Sullivan, PsyD, decides he can push his patient further. Sullivan fiddles with the controls and before his patient's eyes, the warm, welcoming audience transforms to a skeptical, unreceptive crowd. As the patient's anxiety climbs, Sullivan coaches him through the relaxation exercises they've practiced.

Sullivan is the head psychologist at Limbix—a startup producing virtual reality therapy software to help treat anxiety-based disorders with exposure therapy, provide relapse prevention for substance abuse and teach mindfulness and relaxation. He also maintains a private psychotherapy practice in San Francisco. "Now that I've been using it in my own practice, I wouldn't want to give it up," he says.

Virtual reality expands its reachThe Limbix system is among a growing number of virtual reality platforms that psychologists are using to address phobias, post-traumatic stress disorder (PTSD), substance use disorders and more. Virtual reality therapy was first found to be effective more than 20 years ago, when Barbara Rothbaum, PhD, of Emory University School of Medicine, and colleagues demonstrated that virtual reality-based exposure therapy could help people overcome a fear of heights (American Journal of Psychiatry, Vol. 152, No. 4, 1995). In the last couple of years, the field has exploded thanks to newer systems that operate through cellphones, making them less expensive, more portable and a lot more practical than their predecessors. "Even 10 years ago, it cost $30,000 to set up a virtual reality rig, and it was big and clunky and limited. Now that virtual reality can be delivered through mobile technologies, you can do it on a cellphone with a $70 headset," says Sullivan. "For the first time, it's really accessible."

As clinicians and researchers explore the many ways that virtual reality can be of use, it's almost easier to ask: What can't it do?

Fears, PTSD and substance abuse

Even in the early days of virtual reality, researchers quickly recognized that the technology was a great fit for providing exposure therapy, in which patients are exposed to things they fear in a safe place. As a patient makes progress confronting his or her fears, virtual scenes can be adjusted to make the feared stimulus more provocative, says Albert "Skip" Rizzo, PhD, a University of Southern California psychologist who researches virtual reality systems in clinical assessment and treatment. "At its core, virtual reality is essentially a controlled stimulus environment," Rizzo says.

In the real world, exposing people to their fears can be inconvenient or cost prohibitive. Psychotherapists can't always accompany their clients on airplanes or tag along on job interviews. Facing virtual threats is more practical. "With a virtual plane, we can take off and land as many times as we need to in a therapy hour. If my patient isn't ready for turbulence, I can guarantee there won't be turbulence. I have ultimate control," says Rothbaum, whose early research at Emory led to the creation of Virtually Better, a company that develops virtual reality systems for therapeutic use.

Virtual realityVirtual reality may be particularly well suited to exposure therapy for another key reason: People respond physiologically to their virtual experiences. An important part of managing anxiety is learning to control the body's fear response. Virtual reality experiences can trigger reactions such as a racing heart and rapid breathing. "People often think virtual reality won't scare them, since they know it's not real. But it doesn't take a whole lot to tap into that fear," Rothbaum says. "Their brains and bodies fill in the details, and suddenly they are shaking and hyperventilating."

Much of Rothbaum's research has focused on using virtual reality to treat people with PTSD. One well-supported treatment for PTSD is imaginal exposure, in which patients repeatedly recount their traumatic memories and process the emotions that arise. Adding virtual reality can make the therapy even more potent, Rothbaum, Rizzo and colleagues say (Current Psychiatry Reports, Vol. 12, No. 4, 2010). By coupling virtual reality with imaginal therapy, war veterans can revisit the site of a bomb explosion in Iraq or Afghanistan, and disaster workers can return to the scene of the 9/11 terror attacks on the World Trade Center.

"Sometimes even when they are telling their stories, they can sound rote. They're disconnected from their emotions—but we need them to be engaged for treatment to be effective," Rothbaum says. The rich, potent stimulus available through virtual reality—which can include explosions and even provide vibrations through a special vest—enables patients to connect with their emotions and engage more deeply with the treatment. "With a skilled therapist, they learn to confront those memories," she says.

Rothbaum and colleagues have also explored the use of virtual reality to create more objective measures of PTSD. People with the disorder startle excessively in response to sudden movement or loud noise. The researchers placed patients in a standardized virtual reality scene and measured their startle response, demonstrating that they could objectively measure differences in that response before and after treatment. "As self-reported PTSD symptoms decrease, their bodies become less reactive," she says (Journal of Anxiety Disorders, Vol. 28, No. 4, 2014).

Researchers are also exploring the use of virtual reality to help people with substance use disorders. Virtual experiences have been shown to successfully trigger cravings in people being treated for dependence on tobacco, alcohol or illicit drugs. Such cravings can be useful in treatment for addiction, since they give people a chance to practice what they'll do in high-risk situations.

In a traditional treatment scenario, they might imagine what they will say or do if they are offered a glass of wine or if they see a group of co-workers smoking—but those plans remain abstract. With virtual reality, those scenarios come alive, says Rizzo. "You can put somebody in a virtual bar and have an attractive person come up and offer them a drink," he says. "You're putting people in contexts where their urge states are activated and they can practice their relapse prevention skills."

As virtual reality becomes more accessible, researchers and companies are looking for new directions to take the technology. Rizzo has long been interested in exploring virtual reality as a tool for cognitive rehabilitation after stroke or other neurological injury. That's what brought him into the field of virtual reality in the first place. "I was a clinician working in brain injury rehabilitation, and I got frustrated with the tools that we had available to us," he says.

Decades ago, he found he could motivate patients to practice executive function skills by inviting them to play SimCity, a video game that enables players to build computer-generated cities. Virtual reality systems can similarly motivate patients with game-like features embedded in functional, everyday virtual environments, Rizzo says. Imagine a game where players earn points by practicing real-world skills such as preparing a virtual meal. "The technology is finally catching up with the vision," Rizzo adds.

An immersive research tool

Beyond its potential for therapy and enhancing well-being, virtual reality also has promise as a tool for studying and measuring human behavior and cognition.

Virtual reality is an excellent tool for exploring basic questions about human perception and cognition, says Jeanine Stefanucci, PhD, an associate professor of cognition and health psychology at the University of Utah.

"We can manipulate a virtual world in ways that could never be done in a real environment," she says. "For example, we could take away visual aspects of the environment that you might use to navigate, such as street signs or distal mountains, to explore what that means for visual perception or spatial cognition."

One perceptual puzzle for researchers is the phenomenon of vastness, the feeling that the environment around you extends almost forever, making you feel insignificant by comparison. This phenomenon is familiar to almost everyone who has gazed across the open ocean or stared into a starry night sky, and it is often tied to the experience of awe. Yet scientists still aren't sure what visual stimuli lead to the perception of vastness. Stefanucci and colleagues showed they could evoke a sensation of vastness using virtual mountain landscapes, suggesting that virtual reality could be helpful for understanding this complex phenomenon (Proceedings of the ACM SIGGRAPH Symposium on Applied Perception, 2015).

New virtual reality systems also represent a person's body or body parts within the virtual scene, and Stefanucci and her colleagues are using that feature to study how changes to one's avatar might affect perception. They showed, for instance, that enlarging or shrinking the size of a person's virtual foot changed the participant's judgment about his or her ability to step over a gap in the virtual world (ACM Transactions on Applied Perception, Vol. 12, No. 4, 2015).

Similar research using virtual reality could help scientists better understand body image disorders. For example, Jeremy Bailenson, PhD, a cognitive psychologist who heads the Virtual Human Interaction Lab at Stanford University, and colleagues used virtual social settings such as a party and the beach to show that college-age women with and without body image concerns interacted differently with avatars of varying body types. They concluded that virtual reality could be an effective tool for measuring body image disturbance (BID) and for measuring people's response to BID treatment (PLOS One, published online, 2015).

Bailenson's lab is also investigating ways to use virtual environments for the greater good. In one project, he and his colleagues collaborated with marine scientists to create the Stanford Ocean Acidification Experience, a free science education tool designed to inspire environmentally sustainable behavior. The tool allows users to immerse themselves in the ocean of the future to explore the effects of rising carbon dioxide emissions on corals and other marine life. The work builds on a previous study by Bailenson's group that found when people embodied animals in immersive virtual worlds, they felt closer to nature and perceived environmental risks to be more imminent (Journal of Computer-Mediated Communication, Vol. 21, No. 6, 2016).

Proper training required

As virtual reality takes off in so many directions, researchers are enthusiastic—and cautious. Bailenson and Kathryn Segovia, PhD, for example, found that when elementary school-age children watched a virtual version of themselves swimming with whales, many later believed it had happened in real life (Media Psychology, Vol. 12, No. 4, 2009). Bailenson and others caution that more research is needed to understand the risk of creating false memories through virtual reality.

In the clinical arena, Rizzo says he often fields calls from clinicians interested in using virtual reality to treat patients with PTSD, despite their lack of training in trauma-focused exposure therapy. "You need to have that level of clinical skill, to be trained in the traditional method, before you can dig into virtual reality," he says.

As with any therapy, Rothbaum says, there is good virtual therapy and bad virtual therapy. But in the hands of a trained clinician, she says, it is a valuable tool.

And it's a tool that rapidly continues to improve. "As the technology gets better, I think it will become even more creative than what we're seeing now," Sullivan says. "What haven't we thought of yet, simply because we didn't have this tool to use? This can become anything."

APA is hosting Technology, Mind & Society, an interdisciplinary conference exploring interactions between humans and technology on April 5–7 in Washington, D.C. For more information or to register, visit https://pages.apa.org/tms.

How to go virtual

Virtual reality systems for psychotherapeutic use are taking off. Here are some of the companies providing those tools:

  • Virtually Better. Phobias, substance use disorders, skills development, PTSD, stress/pain management
  • Limbix. Exposure therapy for anxiety-based disorders, relaxation, mindfulness, skills training, relapse prevention, pain management
  • The Virtual Reality Medical Center. Fear of flying, pain management, PTSD
  • Beyond Care. Eye movement desensitization and reprocessing therapy (EMDR), pain management
  • CleVR. Fear of flying, fear of heights, psychosis and social phobia
  • Psious. Phobias, PTSD, pain management, ADHD, stress management
Additional reading

Is Virtual Reality Ready to Help Patients?
Sullivan, S.
The California Psychologist, in press

Is Clinical Virtual Reality Ready for Primetime?
Rizzo, A. & Koenig, S.T.
Neuropsychology
, in press

The Use of Virtual Reality Technology in the Treatment of Anxiety and Other Psychiatric Disorders
Maples-Keller, J.L., Bunnell, B.E., Kim, S.J., & Rothbaum, B.O.
Harvard Review of Psychiatry
, 2017

Virtual Reality in the Assessment, Understanding, and Treatment of Mental Health Disorders
Freeman, D., et al.
Psychological Medicine
, 2017