How Can Virtual Reality (VR) Be Used in Therapy?
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Virtual reality refers to a computer-generated environment that provides a 3-D experience. While still falling far short of the Holodeck environments popular among Star Trek crews or Stephen Spielberg’s “OASIS” in the 2018 film Ready Player One, VR technology continues to advance, providing ever more realistic experiences.
Although VR focuses on visual experience, several units currently augment vision with olfaction. Haptic devices like gloves and vibration vests might lead to more realistic touch experiences. Vestibular stimulators, positioned over the ear, are used in gaming to simulate the body’s response to turning, as in a car racing situation.
The quest for immersive experiences is not new. Filmmaker Morton Heilig introduced his Sensorama machine in 1962, featuring 3D images, body tilting, stereo sound, wind, and smell. A handful of “4-D” theatres combined 3D visuals with moving seats and smells, but the concept didn’t really catch on.
The advent of more powerful computers and the public’s thirst for more realistic video games put virtual reality back in the spotlight. So many headsets have been introduced that PC Mag was able to feature an article about the “Best VR Headsets for 2023.”
Just how realistic are these experiences? The answer, of course, is “it depends.” A VR installation in the M/S Maritime Museum in Denmark that simulated a North Sea storm made my daughter and I feel a bit of motion sickness afterward. Walking across a virtual plank at the UC Santa Barbara Research Center for Virtual Environments and Behavior (ReCVEB) failed to trigger my reliable height phobia, but the technology has undoubtedly improved since I last visited.
What is Virtual Reality Therapy (VRT)?
Virtual reality therapy (VRT) uses the technologies described above to help people with psychological issues. Licensed therapists provide VRT. Although various apps are marketed as “therapy,” and might be helpful to some users, they don’t qualify as VRT.
Also distinct from VRT is telehealth, which simply means that computer technology is used for a health or counseling session using programs like Zoom or Teams. However, some therapists consider the use of avatars as instances of VRT. Clients might feel that “opening up” is easier if they use avatars instead of identities, particularly in group therapy settings.
What is Virtual Reality Exposure Therapy (VRET)?
A variation of VRT is known as virtual reality exposure therapy (VRET), which is especially useful in cases of phobia, unrealistic fears (e.g., fear of heights), or in cases of posttraumatic stress disorder (PTSD).
Exposure therapy is a type of Pavlovian counter-conditioning involving gradual exposure to fear-producing stimuli accompanied by trained relaxation techniques. The foundational idea is that fear and relaxation are incompatible, so if a client can learn to relax in the face of fear-producing stimuli instead of freaking out, tolerance for the stimuli can be improved.
For example, a person afraid of snakes might be asked to construct a hierarchy of fearful snake situations from least to most scary. This might include viewing a cartoon snake, then a more realistic image of a snake, handling a plush toy snake, holding a rubber snake, and finally, picking up and holding the real deal. Once the person achieves relaxation at a level, the next is presented. If at any time relaxation fails, the person returns to a previous, successful level.
Exposure therapy has been a standard approach for years but often relies on the client’s imagination to supply the fear-producing stimuli. Imagining yourself in a high place could be very different from being there. Putting clients in real situations is not feasible or desirable, but VRET might be the next best thing.
VRT in Action
Examples of VRET include Spiderworld, brought to us by the Human Interface Technology Lab (HITLab) at the University of Washington. Clients with spider phobia interact first with a virtual spider and then demonstrate their willingness to hold a very large, very real tarantula. In an early version of the VRET, developers were dismayed when a programming glitch made the virtual spider’s legs fall off when clients interacted with them in a certain way. They were determined to fix the program but were talked out of the fix by the clients, who argued that they felt “empowered” when the spider’s legs fell off.
Veterans with PTSD use Virtual Iraq, a program that exposes the clients to various scenes designed to augment their other psychotherapy. You can see a walk-through of the program here.
VRT particularly interests therapists working with clients with autism spectrum disorder (ASD). The client can “walk through” various social situations and problem scenarios under the therapist’s guidance. Developers are also interested in simulating the experience of people with ASD, which would allow teachers and family members to gain understanding and empathy about the challenges ASD presents.
On a different note, VR therapy has also been used to help people with phantom limb pain. The technology “tricks” the brain into thinking the limb is still there, reducing the client’s pain and discomfort. Burn victims experience reduced pain during otherwise difficult movement therapy sessions using VR programs featuring a snowball toss game.
Finally, VR shows considerable potential in rehabilitation programs for brain injury patients. Patients in hospital settings might receive at most one or two sessions of therapy a day from a real person, but VR makes it possible for the patient to engage in therapy as many hours as their energy levels and pain levels allow. Because most recovery from brain injury occurs within the first six to 12 months, time is of the essence.
Initially, healthcare professionals believed that special games were needed for this purpose, but they eventually realized that off-the-shelf games worked just as well, especially those that featured movement. As a result, the term “WiiHab” was born.
Challenges for VR Therapy
VRT and VRET demonstrate significant potential for helping certain people with psychological problems, but challenges remain.
First, the realism of the programs, although improving, might not provide an adequate experience for some clients. As I mentioned previously, my hair-trigger height phobia was not at all stimulated by my VR experience. I found this surprising, as I often experience a vicarious physical response when I see a photo or video of a person in a very high place (think about any Tom Cruise scene from the Mission Impossible series).
Second, developers need solid information about what situations would be most helpful for people, requiring them to have at least a working understanding of psychological disorders. At the same time, psychologists assisting in the development of VRT and VRET must also have a working understanding (and vocabulary) with which to communicate their goals to the developers.
Third, the number of therapists trained to administer VRT and VRET is tiny. We don’t really know exactly what such training should entail or how we know whether a therapist is qualified to provide VRT and VRET.
Finally, much research must be done to establish the efficacy of VRT and VRET. Finding a reasonable placebo and conducting an ethical placebo group are just a few methodological challenges researchers face.
VRT and VRET and any innovations yet to come will probably never substitute for traditional psychotherapy. However, as an adjunct tool to that therapy, they have the potential to make many lives better.
Laura Freberg, PhD
Writer & Contributing ExpertLaura Freberg serves as professor of psychology at Cal Poly, San Luis Obispo, where she teaches introductory psychology and behavioral neuroscience.
Dr. Freberg is the author or co-author of several textbooks, including Discovering Psychology: The Science of Mind, Discovering Behavioral Neuroscience, Applied Behavioral Neuroscience, and Research Methods in Psychological Science. She served as President of the Western Psychological Association (WPA) in 2018-2019.