Virtual Reality – a Valuable Tool to Advance Treatment of Mental Disorders

Archives of Psychiatry and Psychotherapy, 2019; 1: 65–73

DOI: 10.12740/APP/101654

Virtual reality – a valuable tool to advance treatment of mental disorders

Anna Grochowska, Marek Jarema, Adam Wichniak

Summary Human-computer interactions are a new path of treatment in mental healthcare. Virtual Reality technology is an interesting example of a digital tool that can be used in the treatment of mental disorders. It may be useful for improving personal competencies or overcoming deficits. This paper presents a range of successful VR applications in psychiatry and psychology. VR was found to be effective in the treatment of anxiety disorders, PTSD, schizophrenia, eating disorders, and substance use disorders. Repetitiveness of virtual experience in a particular environment offered by VR technology makes it a promising option in the treatment of mental disorders. Another asset of VR is a good control of intensity of therapeutic interventions that can be regulated by a therapist. Moreover, at the VR session can be individualized for each patient and it may be adapted to his/her personal preferences and needs. VR offers sense of “being here and now” during the session. It is also an engaging method of training for patients who do not want to use the conventional training techniques. Recently, VR use has become more available and acknowledged. However, there are still certain limitations for its broader use in the sector of mental health. The most significant one being the high cost of VR software designing, as well as VR hardware devices, which are still too expensive for mass adoption.

virtual reality, psychotherapy, psychiatry, cyberpsychology

INTRODUCTION ing main stream psychology in the 60’s, now, in the wake of 21th century, we can observe a new New digital technologies are now entering all trend that is already ahead of all convention- aspects of our lives. One hundred and sixty al forms of treatment in mental health. It is cy- years after the nascence of Freud, we are wit- berpsychology, psychology based on human- nessing the moment when computational sci- computer interaction. ence is merging with the field of psychiatry and Thanks to the use of certain digital devices, psychotherapy. Long after the beginning of 20th it is possible to introduce a human being into century and the psychoanalytic revolution in a selected three-dimensional environment and the understanding of human behavior, and after make him/her interact with a computer-gen- the cognitive-behavioral approaches conquer- erated world by multi-sensory channels. This technology is called Virtual Reality (VR) and it was first described in 1986 by Jaron Lamier. Al- 1Anna Grochowska, 1Marek Jarema, 1Adam Wichniak: 1Third Department of Psychiatry, Institute of Psychiatry and Neurology, though technology avenues have advanced a lot Warsaw, Poland since then, the idea itself has not change. VR still Correspondence address: [email protected] involves three core dimensions, ie. 1/ The first is 66 Anna Grochowska et al. an immersion usually achieved by head mount- a controlled exposure to specific stimuli nor- ed display.; 2/ The second one is an interaction, malizes affective regulation. The use of VRET is which is possible thanks to electronic gloves or fast-developing and spreading fast to the clinical trackers.; and 3/ The third one is a subjective practice, with each month bringing several new “sense of presence” which refers to the aware- and excellent studies and meta-analyses on the ness of physical participation in the digital cre- subject. A majority of studies that investigating ated world [1]. VRET [4–6] demonstrate its effectiveness. How- The two most common modes of VR appli- ever, comparisons of VRET and CBT-SD did not cation are exposure-based therapy and behav- show any significant differences between the ef- ioral skills training (2). VR enables doctors and fects of the two forms of therapy [5]. An experi- psychologists to observe the patient’s behavior mental study of Triscari [7] suggests the same ef- and interactions with virtual objects or stimuli. ficacy of those two approaches. The study com- Depending on the training goal, it also allows pared group of patients with aerophobia receiv- them to control and modify environment. Pa- ing either CBT treatment combined with SD tient’s particular experience is evoked in order (both in vivo exposure and imaginal exposure) to improve his/her competencies or overcome or CBT fortified with VRET [7]. Linder [8] dem- limitations. Researchers have tried to use VR in onstrates high efficacy of both self-led (conduct- the treatment of various mental disorders. It was ed at home) and therapist-led VRET in patients reported as a valuable tool for treatment of anx- suffering from public speaking anxiety (PSA). iety disorders, substance dependence, obesity, Nevertheless, in his research the comparison of eating disorders, and schizophrenia (3). The aim VRET with traditional face-to-face CBT therapy of our review is to present most significant ap- that was drawn from meta-analysis showed no proaches to VR treatment and to reflect future significant difference in therapeutic progression. possibilities for VR use in therapy of the mental Emmelkamp’s findings demonstrate that VRET, health disorders. a method that makes people experience a “sense of presence” during treatment, is an equivalent to CBT with in vivo exposure. Thus, it provides Application of VR in the treatment of anxiety better therapeutic outcomes than CBT with im- disorders aginal exposure. A meta-analysis of 14 clinical trials of the VRET application in patients suffer- According to the Turner and Casey’s meta-anal- ing from specific phobias confirmed important ysis of clinical trials, a majority of previous VR behavioral improvement right after VR training applications in mental health were associated and also during a post-treatment assessment [9]. with specific phobias e.g., social phobia, arach- However, there were again no significant dif- nophobia, acrophobia, aerophobia etc. [2,4]. ferences between VRET and CBT in vivo expo- A person suffering from a specific phobia expe- sure. In turn, Freeman’s results [10] suggested riences augmented amount of anxiety, related that VRET could in fact be the more beneficial to a particular item or situational context, which intervention. He applied VRET to patients with results in avoidance of situations or objects that fear of heights (acrophobia) who were assisted trigger it. and guided by virtual coach created with actor’s The traditional and widely accepted method- voice and motion capture technology. The ef- ology of managing this problem is cognitive – fects of this form of treatment exceeded those behavioral therapy integrated with systematic of the therapist-assisted interventions and were desensitization (CBT-SD) based on the exposure comparable to the effects of best psychological in vivo or imaginal exposure. interventions reported in a meta-analysis of re- The digital modification of this therapy is Vir- searches on phobia treatments. In a meta-anal- tual Reality Exposure Therapy (VRET). It differs ysis of studies on VR therapy of anxiety disor- from the conventional one in the manner of ex- ders prepared by Fernandez-Alvarez [11] were posure. VRET users are directly immersed in the examined post-treatment deterioration rates. virtual reality world with a digital presence of Findings show very low deterioration frequen- a particular feared stimulus. In both techniques cy, which leads to a conclusion that there are no

Archives of Psychiatry and Psychotherapy, 2019; 1: 65–73 Virtual reality – a valuable tool to advance treatment of mental disorders 67 harmful effects of using VR interventions in the negative self-esteem can lead to a deterioration treatment of anxiety disorder. in a schizophrenic symptoms after exposure to VRET has proved to be a promising form of social stressors. treatment also in the case of patients suffer- Another important VR implementation in the ing from post-traumatic stress disorder (PTSD) treatment of schizophrenia involves different [6,12,13]. Findings show high effectiveness of programs of cognitive rehabilitation. People suf- VR approach to PTSD treatment after various fering from schizophrenia usually manifest dif- traumatic events. However, it does not seem to ferent dysfunctions within attention, processing provide better improvement than application of speed, learning and memory, problem solving, traditional treatment options, such as imaginal executive functions, and social cognitions. There prolonged exposure, eye movement desensiti- is evidence that VR techniques are effective in zation, pharmacological interventions or others. amelioration of related neurological symptoms [6,12,13]. Nevertheless, the use of VRET in PTSD [17,18]. VR was also reported to be effective is widely explored and each year brings new method of Social Skills Training (SST). SST im- findings. Norr et al. [14] showed that VRET can proves patients’ quality of life and it is benefi- be more effective than conventional therapies if cial in their day-to-day functioning. By reinforc- applied to younger populations, also indepen- ing social and cognitive skills, both the schizo- dently people not taking antidepressants, group phrenia symptoms and related deficits can nota- with higher hyperarousal symptoms and great- bly decrease. When using VR-based treatment, er suicide risk. All this implies that the choice of it is possible to create virtual environment sim- type of the treatment should be personalized to ilar to patients’ daily lives what makes it possi- each patient. ble for them to practice their social performance in many dimensions. During a VR session, a patient can meet and interact with animated agents Application of VR in the treatment of schizophrenia (avatars), thus work on his/her direct communication skills. Patient’s activation and freedom of Another mental disorder where VR therapy reactions in virtual environment creates an op- application has been widely explored is schiz- portunity to gain the corrective experience. VR ophrenia. VR technology has enriched cogni- application appears to be successful in improv- tive-behavioral interventions for schizophrenia. ing social cognition and social skills of schizo- There are many important utilizations of VR as phrenia patients [19]. In 2014, Rus-Calafell et al. far as assessment and treatment of schizophre- used a VR treatment program based on Soski- nia are concerned [15], eg. One of them is assess- train scenarios treatment that included working ment of positive symptoms severity in patients’ on seven areas of social activity: emotion recog- daily lives. Psychotic experiences such as hal- nition, interpretation of expressions and inten- lucinations or paranoid ideation can be directly tions, expressing emotions, assertive commu- reported by patients during a VR session [15]. nication, interactional and conversational skills Persecutory ideation in VR environment differs [20]. The treatment reduced patients’ social anxi- among clinical and non-clinical groups and this ety and discomfort. In addition, the training out- is why VR can facilitate assessment of patients comes included improvement in learning emo- with schizophrenia and schizophreniform dis- tion perception, assertive behaviors, and longer orders. Freeman et al. found that the delusional time spent in a conversation. It was found that clinical group was 12 times more likely to report an integrated VR program for social skills train- persecutory ideation during a VR session [15]. ing (SOSKITRAIN) reduced negative schizo- Virtual reality scenarios can be also used to ob- phrenia symptoms [19]. What deserves special serve interdependence of schizophrenic symp- attention is the fact that VR SST in schizophrenia toms and some personal risk factors. Jongeneel treatment seems to be an interesting method for et al. [16] aimed to manipulate the virtual envi- patients who usually have no interest in conven- ronment that influenced the liability to psycho- tional SST. Most of schizophrenia patients dem- sis and found a self-esteem to be a modulator onstrate little or no motivation for traditional of psychotic responses. They demonstrated that forms of training, which greatly hinders their

Archives of Psychiatry and Psychotherapy, 2019; 1: 65–73 68 Anna Grochowska et al. progression and improvement. Hence, VR tech- ulate their negative emotions related to the voic- nology is especially useful in that respect as it es they hear. In theory, this is also a way to prac- seems to attract patients and increase their will- tise assertiveness and strengthen personal sense ingness to participate in SST [21]. of self. The results demonstrating the effective- Furthermore, the implementation of VR was ness of AT were replicated also in subsequent found to be beneficial also in vocational reha- study conducted by the same research team [23]. bilitation of patients suffering from schizophre- Schizophrenia symptoms, particularly audito- nia. In 2013, Tsang and Man [17] reported some ry verbal hallucinations and depressive mood remarkable results. They used a shopping mall were reduced after treatment. Nevertheless, Per- scenario to practice patients’ problem-solving cie’s therapy is not the only novel approach to skills and their communication with other peo- psychosis treatment. There is an entire range of ple by playing a shop assistant role. The tasks Virtual Reality Assisted Therapies dedicated to varied from simple and easy to more elaborate schizophrenic patients. Recently there have been ones, and patients were given a direct feedback attempts to implement VR-CBT interventions in- during their performance. The results of the volving the use of avatars which match to the study revealed significantly better work perfor- patients’ paranoid ideations. [24]. Patients are of- mance and self-efficacy after VR training than fered a possibility to challenge their delusional after application of compared but more conven- suspicious thoughts by interacting with their av- tional non-VR trainings. The advantage of vir- atars in a direct way. AT proved effective in re- tual reality vocational training system (VRVTS) ducing patients’ feeling of anxiety and momen- has an asset of the potential infinite number of tary paranoia, and its effects exceeded those re- performance repetitions [17]. Patients can get ported in the control group treated with tradi- a complex task involving multiple cognitive tional CBT interventions. functions. The VR experience is similar to a real-life one, but is less demanding and stressful. What is more, patients can receive an immedi- Application of VR in the treatment of eating ate feedback and can change the level of task disorders difficulty depending on their personal learning speed. Similar systems of vocational rehabili- VR protocols were also addressed to patients tation could be created for countless scenarios with obesity and eating disorders: anorexia, bu- and job contexts. VR could thus become a valu- limia nervosa, and compulsive eating disorder able tool to considerably increase employabili- (ED). All these disorders share some common ty of patients suffering from schizophrenia. As features: unhealthy weight-control behaviors an employment is an essential element of hu- and body image disturbance [25]. In particular, man psychological balance, due to positive- therapy can focus on regulation of eating habits ly affecting self-image identity and providing or working with personal body image to con- a sense of hope, it is also an important for im- vert it into positive and satisfactory one. Con- proving patients’ mental health and combatting ventional, widely-accepted forms of treatment the illness [17]. of eating disorders includes cognitive-behavioral VR has proved in therapy of schizophrenia interventions teaching patients how to change not only in terms of aiming cognitive or voca- their patterns of thinking and behaviors. How- tional rehabilitation. There are novel therapies ever, as all these disorders have slightly differ- that have recently emerged thanks to the VR ent clinical presentations, there is a need to de- technology. Percie du Sert et al. [22] construct- velop efficient and comprehensive methods for ed a virtual scenario enabling schizophrenic pa- their treatment. Applying VR to the therapy of tients to interact with their auditory hallucina- ED proved to be meaningful for both, assess- tions. Namely, a patient can converse with a rep- ment and treatment [26,27]. resentation of his persecutory voice. It is called In 1999, Perpiñá and his research team were Avatar Therapy (AT) and it seems beneficial in pioneers with their findings that VR environ- terms of therapeutic targets in a relational ther- ment could be more efficient in therapy of body apy approach. Patients learn how to better reg- image (BI) disturbance, than a Standard Body

Archives of Psychiatry and Psychotherapy, 2019; 1: 65–73 Virtual reality – a valuable tool to advance treatment of mental disorders 69

Image Treatment (SBIT), which – at that time – with a patient suffering from bulimia nervosa, consisted of cognitive-behavioral techniques and Ronceroa and Perpiñá introduced VR as a part relaxation [28]. Body image refers to the men- of complex cognitive-behavioral treatment [30]. tal perception of one’s own body. In virtual re- VR sessions were to help the patient regain con- ality one can create subjectively perceived and trol over her behaviors, plan her meals and cre- desired body image by manipulating a virtual ate new, healthy eating habits, eg. eating in the three-dimensional human figure, making dif- same place or focusing on eating. In the sec- ferent body parts bigger or smaller on demand ond stage, the patient was exposed to image of [26]. The patient can notice and discuss any dis- unhealthy food and encouraged to replace un- crepancy between reality and his/her imagina- healthy behaviors and distorted thoughts with tion. It is a useful tool to help the patients under- more adequate ones. In this research, the VR stand that perception of their own body is basi- proved to be an important part of treatment cally a relative concept. strategy, as it reduced bulimia’s symptoms and Another reason to apply VR to correct a dis- dysfunctional behaviors, including binges, vom- torted body image is to try to make it more real- its, food avoidance, and fear of eating. After the istic and positive. This approach is represented treatment, the patient was more able to control by Riva [29], who based his findings on the “al- impulses and scored better results on psycho- locentric lock theory”. The theory explains obe- pathology scales. Meanwhile, the search for the sity and eating disorders as a consequence of right methodology of implementing VR to the an “allocentric negative body image”, which is treatment of ED and obesity still continues in a distorted perception of one’s body. It is a con- various laboratories around the world. sequence of the feedback about one’s body re- ceived from others and internalization of those Application of VR in the treatment of substance use opinions. What is more, the distorted self-per- disorders ceptions are too firm to allow any information to update, even after evident body changes, for Researchers are also trying to find the right example significant weight loss. VR-based body- way to introduce Virtual Reality techniques into image protocol developed by Riva allows intro- therapy of substance use disorders (SUD), in- ducing changes into the personal perception of cluding drug, alcohol and nicotine dependence. one’s body. This treatment protocol involves re- The most broadly examined use of VR in SUD living past experience in Virtual Reality with the is connected with a treatment of nicotine de- support of a psychotherapist, and at the same pendence [4]. VR approach to the smoking ces- time expression of feelings. This way, a user is sation is based on Cue Exposure Therapy (CET). able to recognize cognitive errors in their per- It is well known that smokers develop a connec- ception of various situations and to interpret tion between smoking a cigarette and diverse them in a different way. They can also experi- “cues” which include specific places, objects ence a given situation from a third person per- or people [31]. It was demonstrated that those spective and thus change the negative view con- cues can elicit an urge to smoke, called a crav- cerning their bodies or any other body-related ing, which is considered the main source of ad- misperception they might have. Riva’s compre- diction itself. Thus, the presence of a particular hensive VR-based CBT treatment resulted in cue can trigger a compulsive smoking behavior a significant patient improvement [29]. or can relapse in return for ex-smokers. A nico- The treatment based on changing eating hab- tine-dependent person usually associates smok- its aims to normalize patients’ disturbed eating ing with social situations or daily activities that patterns. During a VR session it is possible to cannot be avoided. In Virtual Reality CET, a pa- uncover a trigger for abnormal eating behavior tient is repeatedly exposed to the trigger that [26]. In simulated real-life situation one can ob- provokes craving in order to extinguish the cue- serve a cue-elicited emotional response. Taking reactivity [32]. VR environment is designed in this into consideration, many researchers try to the way that confronts the patient with his/her create the procedures for treating individuals particular cues. It is customized to include his/ suffering from eating disorders. In their work her smoking-related triggers e.g. specific items,

Archives of Psychiatry and Psychotherapy, 2019; 1: 65–73 70 Anna Grochowska et al. people or situations. During a VR CET session, orders. Some researchers try to tailor VR to the the patient is immersed in virtual surroundings therapy of sleep or sexual dysfunctions, like pre- and tries to apply previously acquired coping mature ejaculation or impotence for instance. skills to endure exposure to cues. Virtual Reali- However, due to the relative scarcity of data, it ty CET proves effective in reducing craving and, is impossible to evaluate the effects of VR use in in consequence, leads to higher quitting rates therapy of these disorders. Furthermore, VR was and lower number of cigarettes smoked daily reported to be a valid method of cognitive re- after a treatment [31]. Some findings also sug- habilitation, applied to help patients with some gest that VR environment can elicit better cue- neurological problems, including dysfunctions induced craving than the less advanced meth- after brain lesions, strokes or spinal cord inju- ods, including the traditional cue exposure [33]. ries. VR has also some medical applications in It seems that there is common belief among re- physical rehabilitation. searchers that the future possibilities of VR tech- What is more, recent studies present endeav- nology can notably enhance the efficacy of sub- ors to use VR in all sorts of non-clinical settings, stance abuse treatments, including those related such as skill or self-development training, for to alcohol and drug dependence. example, for acquaintance of relaxation, spatial skills training, improving peripheral vision etc. Application of VR in the treatment of other mental It was also reported that VR approach is signif- disorders icantly more effective than some widely accepted standard programs for management and pre- Beside the already mentioned most common vention of psychological stress [34]. These are and explored implementations of VR in mental just a few examples of potential directions and health care, there are also enthusiastic attempts domains where adaptation of VR technology to apply it in the treatment of other mental dis- could be beneficial.

Table 1. Comparison of VR treatment and conventional one in mental disorders (placed at the end of document). Mental disorder Conventional treatment VR application in treatment Comparison of VR method with a conventional treatment Specific phobia Cognitive behavioral therapy Virtual Reality Exposure VRET=CBT-SD in vivo integrated with systematic Therapy (VRET). VRET>CBT-SD imaginal desensitization (CBT-SD) exposure Schizophrenia Assessment of presence of Assessment of presence of Various data positive symptoms positive symptoms in VR Various data Cognitive rehabilitation Cognitive rehabilitation in VR VRVTS > Cognitive Cognitive vocational training environment vocational training Virtual reality vocational training system (VRVTS) Eating disorders (ED) Cognitive changing eating Changing eating habits in VR No significant data habits VR Body Image Treatment VRSBIT> SBIT Standard Body Image (VRSBIT) No data Treatment (SBIT) VR Body Image Treatment based on “allocentric negative body image Substance use disorders (SUD) Cue Exposure Therapy Virtual Reality Cue Exposure VRCET > CET (CET) Therapy (VRCET)

Archives of Psychiatry and Psychotherapy, 2019; 1: 65–73 Virtual reality – a valuable tool to advance treatment of mental disorders 71

DISCUSSION ising option for all the patient-centered forms of therapy instead of pathology-centered prac- The patient’s full immersion that is offered by the tice [3]. During VR experience, patients are ful- use of virtual reality brings many advantages to ly involved into their therapeutic process, which therapy, and while the same effect is much more seems to be crucial for the success results of each difficult to achieve with previous, traditional treatment. Virtual reality protocols applied to treatment options. Discovering a new, comput- help a concrete user are based on his/her specif- er-generated world can be exciting and engaging. ic personal needs. The exploration of patient’s A variety of feasible interventions makes it pos- preferences, thoughts and emotions makes him/ sible to tailor the environment to one’s particular her feel important and allows the active partici- preferences. Apparently, even patients with se- pation in the recovery process. vere mental illnesses agree to work with VR tech- VR devices are becoming more and more nologies and more importantly, they consider it available. In the last few years, several huge a very attractive treatment option and express commercial companies have released into the a huge interest in experimenting with this type general market some VR systems that are afford- of help [1]. The use of a new VR technology can able for an individual user. An advantage of VR significantly enhance the motivation for rehabil- over traditional cognitive behavioral therapy itation in people with mental disabilities [21]. Be- (CBT) is that it does not always require a thera- sides, the VR enables interaction with “real-life” pist’s presence, so it can be cheaper in the long- avatars and places. A patient becomes an active term use. The big interest and demand for VR participant of a newly-constructed, virtual world. on the market accelerates the process of its adap- Users usually experience a “sense of presence”, tation for at-home use. It is therefore anticipat- which refers to a psychological concept of “be- ed that self-guided trainings and self-assessment ing here and now” and elicits subjective impres- VR programs will soon appear on the market. sion of really being inside the simulated envi- Unfortunately, it is still within the realm of ronment. It is sometimes defined as “the feeling dreams and expectations that future when VR of being in a world that exists outside the self” interventions will be commonly available in the [35]. VR users also have a feeling of “social pres- public mental health care sector. For the time be- ence” which means that they consider the inter- ing, the high cost of software designing hinders action with people or animals that seem to move the popularization of this technology. The devel- and exist real. The “sense of presence” can be es- opment of one particular virtual scenario costs pecially important for patients with severe men- hundreds thousands of euro, and therefore VR is tal illnesses like schizophrenia [21]. They do not currently more accessible in research centers and need to rely on their imagination, but rather they institutions than in the public or even private can be confronted with a new three-dimension- healthcare facilities. Moreover, software is still al environment, shaped to resemble their previ- largely under construction process and is not yet ous experiences and are offered an opportunity good enough to be repetitive, changeable, and to cope with difficulties they tend to encounter applicable enough to be used in the treatment of in their everyday lives. many different dysfunctions. The VR treatment What is even more important, the interaction frequently consists in reconstruction of one’s and dynamics of stimulation in VR may be well individual experience. A VR environment de- controlled. It enables both patient-therapist and signed especially for a particular individual can therapist-patient direct feedback. It is possible be considered useless when applied to a patient to put an experience on hold and thus prevent with slightly different experiences. Therefore, it to go through non-therapeutic situations with is not a multi-contextual tool until now and it errors in learning. It can be paused also to in- still cannot serve in widespread clinical use. troduce other therapeutic techniques or to start In recent years, we have witnessed a huge a discussion, which makes treatment more com- technological leap forward in VR techniques and prehensive and supervised [36]. utilization and we can assume that VR technol- Virtual reality is not just an innovation to ogies will shortly become more flexible and will be used in medical services, but also a prom- be used in daily psychological and psychiatric

Archives of Psychiatry and Psychotherapy, 2019; 1: 65–73 72 Anna Grochowska et al. practice. We can expect VR to be applied in the systematic desensitization, cognitive behavioral therapy com- treatment of a wide range of dysfunctions, life bined with eye movement desensitization and reprocessing strains, and crises and as well as used to enhance therapy, and cognitive behavioral therapy combined with vir- personal competencies and skills. The hardware tual reality expo. Neuropsychiatr Dis Treat., 2015;11:2591- that is continually more available for a general 2598 market reinforces the development of VR appli- 8. Lindner P, Milo A, Fagernäs S, Andersen J, Sigeman M, An- cations and software for specific groups of cli- dersson G, et al. Therapist-led and self-led one-session vir- ents. 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