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Virtual Reality (VR) has significantly influenced the healthcare industry, with extensive applications in both training and patient education and care.

In the realm of psychology specifically, numerous studies indicate that VR exposure therapy can provide various benefits for patients.

But what precisely does VR exposure therapy entail, and how is it implemented?

What is VR Exposure Therapy?

To comprehend what Virtual Reality Exposure Therapy (VRET) is, we first need to break down the term into its two parts: VR and exposure therapy.

Virtual Reality (VR)

VR refers to computer-generated technology designed to create a simulated environment. Utilizing VR headsets, a user finds themselves immersed in a particular 3D world that they can engage with.

Within this environment, many senses can be activated (sight, sound, touch, and occasionally smell), which helps to fully immerse the user in the artificial setting.

Exposure Therapy

The American Psychological Association defines exposure therapy as a psychological treatment developed to assist individuals in confronting their fears.

Individuals with fears (such as heights, flying, or spiders) often avoid situations or activities that trigger these fears. Although this may temporarily alleviate anxiety, over time, the fear may intensify.

In exposure therapy, a psychologist establishes a secure environment that incorporates those fears, enabling the patient to confront them and ultimately lessen avoidance and anxiety.

VRET

Now that we grasp the individual meanings of VR and exposure therapy, we can understand that VRET is a form of exposure therapy that employs VR technology to help expose patients to a safe environment where they can face and diminish their fears.

How do patients begin with VRET?

Typically, patients start VRET by getting acquainted with their therapist and discussing in detail what led to their trauma. The therapist will then create a customized VRET environment designed specifically for that patient.

To commence the therapy, patients will don a VR headset featuring a simulated environment that replicates their trauma. There may be sounds, sights, vibrations, or smells aimed at re-creating the experience and eliciting an emotional reaction.

This process exposes patients to what they may be trying to evade. Through this method, they can confront the situations that instill the most fear in them.

Following the session, patients engage in a discussion about their experience with their therapist, who will gain insight into their trigger points and how to best assist them in recovery as they move forward.

Is it effective?

VRET is still a relatively recent form of therapy, so research continues regarding the complete advantages of this approach. Nonetheless, several studies have already demonstrated its potential effectiveness.

For instance, Jimmy Castellanos, a Veteran Marine Corps member, experienced post-traumatic stress disorder for an extended period after his service in Iraq. His psychiatrist suggested this method, which virtually transported him back to the traumatic memory repeatedly until his triggers ceased to generate anxiety.

Castellanos remarked on the experience:

• It was an entirely different experience. I don’t recall having a physical reaction…In just 13 weeks, I had transformed who I had been for the prior ten years. Before the treatment, 80-90 percent of my dreams were related to Iraq. Now, I can’t remember the last time I had one. I lead a completely different life now.
• It is well known that soldiers returning from combat zones frequently suffer from PTSD. Recent advancements in VR technology have enabled these veterans (and many patients dealing with PTSD, anxiety, etc.) to finally receive the assistance they need and deserve.

Why is it effective?

VRET has demonstrated remarkable benefits in addressing various disorders, particularly PTSD, anxiety, and phobias.

Regrettably, these disorders are currently on the rise — The CDC has reported a notable increase in anxiety disorder symptoms. Many healthcare professionals in the U.S. have also noted rising PTSD rates amid the ongoing COVID-19 pandemic.

The effectiveness of VRET lies in the fact that individuals often develop anxiety and avoid situations that may remind them of a traumatic event. However, VRET encourages them to confront such situations.

For example, a war veteran with PTSD triggered by military combat might react strongly to the sound of fireworks. VRET allows them to face such triggers in a controlled setting. With prolonged exposure, they learn coping mechanisms for the anxiety and reframe their thoughts and feelings regarding a particular event.

Ultimately, the patient becomes accustomed to the triggers, embraces the experience, and their anxiety or stress response diminishes in intensity.

The same principle applies to using VRET for other forms of PTSD, anxiety, and phobias.

VRET vs. In Vivo Therapy

Historically, many psychologists have utilized “in vivo” therapy, which involves guiding patients through exposure-based activities face-to-face. For instance, an individual dealing with agoraphobia may be taken to a public location to help confront their fears, or someone who has a fear of flying might visit the airport with their therapist to replicate the experience of boarding a plane.

While this therapy can be effective, it often depends on the patient’s ability to move and their access to environments that allow them to face their fears without becoming overwhelmed, making it challenging to identify appropriate settings. In contrast, VRET enables therapists to adjust the exposure intensity according to the patient’s circumstances, supporting them in gradually confronting their fears over time. Furthermore, this type of therapy can occur remotely from any location, broadening access to patients beyond those who may benefit from in vivo therapy.

VRET represents a promising new approach for various mental health challenges, and this groundbreaking technology is likely to positively influence the lives of many patients.

Augmented reality, or AR, involves overlaying digital information onto real physical objects or environments—think of the Pokemon Go phenomenon from a few years ago.

However, AR can serve more purposes than just capturing animated characters in real life. In the medical field, it has applications in training, educating patients, assisting during surgeries, and other related functions.

Advances in both hardware and software have paved the way for numerous new and cost-effective applications of AR in healthcare, even for small medical practices. AR tools can be utilized through specific headsets, special eyewear like Google Glass, smartphones or tablets, or other specialized AR devices.

Let’s explore some of the ways AR can enhance healthcare in medical education and practice, as well as in consumer health applications.

AR for Medical Students and Practitioners

For medical professionals—including surgeons and nurses—understanding a patient’s anatomy is crucial before performing any medical procedure. AR can assist by showing visualizations of what lies beneath the skin, increasing accuracy in injections or incisions, or simply providing a clearer view of human anatomy.

At Case Western University’s medical school, for example, students can utilize Microsoft’s Hololens to observe a large 3D model of the human body, allowing them to navigate holographic representations of various tissue layers, muscle, and bone, thus enhancing their anatomical knowledge beyond what’s available during real procedures.

Nurses can employ AR handheld scanner technology to visualize their patients’ veins, making it easier to locate the vein for blood draws or vaccinations. This innovation saves time in vein identification while ensuring patient comfort throughout the process.

Surgeons can leverage AR to gain an augmented sense of vision. By using AR headsets featuring eye displays that project images of the patient’s internal anatomy derived from CT scans, they can obtain a much clearer understanding of the underlying structures. At Johns Hopkins, neurosurgeons have implemented this technology for tasks such as inserting screws during spinal fusion and excising cancerous tumors from patients’ spines.

“When augmented reality is used in the operating room, it functions like having a GPS navigator before your eyes in an intuitive manner, eliminating the need to glance at a separate display to check the patient’s CT scan,” explains Timothy Witham, M.D., director of the Johns Hopkins Neurosurgery Spinal Fusion Laboratory and a professor of neurosurgery at the Johns Hopkins University School of Medicine.

AR has also proven advantageous in allowing doctors to minimize their teams to limit potential COVID-19 exposure. Imperial College Healthcare NHS Trust used Microsoft HoloLens 2 and Dynamics 365 Remote Assist to provide doctors with hands-free video consultations with other specialists during procedures while enabling them to access medical notes and X-rays within their direct line of sight.

“This means that all the information and specialist care you require at the patient’s bedside is readily available, all through one headset,” stated Dr. James Kinross, a surgeon and senior lecturer at Imperial College.

Although the technology is still in its early stages, it is likely that medical schools and practices worldwide will harness the advantages of AR-assisted surgeries and other medical procedures. AR provides access to in-depth insights into patient medical data and anatomical information, which medical professionals and students can learn from and rely on during their operations. It represents a cost-effective and convenient means of gaining “x-ray vision” to enhance their performance in their respective tasks.

AR for patient care and education
AR offers numerous advantages for patients as well

For instance, during a Google Glass trial with the Australian Breastfeeding Association, nursing mothers wore Google Glass while consulting with virtual lactation consultants. This allowed the consultants to view exactly what the mothers were experiencing and provide valuable feedback and advice to enhance their nursing sessions—without requiring the mothers to set their babies down.

Patients can enhance their understanding of drug interactions through an app that scans drugstore shelves and generates alerts about which over-the-counter medications might negatively interact with their existing prescription drugs. The app, offered by Cigna, aids patients in reducing anxiety, preventing adverse reactions, and boosting the efficacy of their medications.

Lastly, AR can encourage individuals to prioritize their health by gamifying physical activity. Applications like Pokemon Go and Ghostbusters World offer a fun and engaging experience that promotes increased walking or running as part of daily routines.

The augmented reality market in healthcare is currently expanding at a compound annual growth rate of 32.9%. As hardware and application developers create more affordable AR technologies, and as medical practitioners, educators, and consumers recognize their value, AR is expected to play a larger role in our healthcare experiences, both at home and during office or operating room visits.

Researchers are continually investigating and improving virtual reality exposure therapy for mental health care, specifically in treating PTSD, anxiety, OCD, and various other mental health issues.

Virtual reality is becoming an increasingly important tool across different industries, and healthcare is no exception. The introduction of virtual reality in surgical training, pain management, management of neurological disorders, pediatrics, and mental health care has yielded distinct and multifaceted advantages for the healthcare system. As research into virtual reality in healthcare progresses, an increasing number of mental health professionals are considering its role in exposure therapy for treating fear-based or anxiety-related conditions.

Exposure therapy, which dates back to the 1900s, has been extensively utilized to manage and treat mental health disorders. Despite its proven effectiveness, there are many limitations in terms of accessing and initiating exposure therapy, as well as maintaining its continuity. With personal and safety obstacles posing challenges, researchers have turned to innovative virtual reality technologies to address some of these issues. However, even the most advanced technologies face their own set of challenges.

Exposure Therapy

Exposure therapy is utilized to treat a variety of mental health disorders, including phobias, panic disorders, social anxiety, generalized anxiety, obsessive–compulsive disorder (OCD), and PTSD.

The American Psychological Association (APA) identifies four primary categories of exposure therapy: in vivo exposure, imaginal exposure, interoceptive exposure, and virtual reality exposure.

In vivo exposure involves real-life, direct interaction with a specific situation or activity that may trigger symptoms. For example, someone with acrophobia, or fear of heights, might go on a rollercoaster or ascend a mountain. A person afraid of public speaking may be asked to deliver a speech.

Imaginal exposure requires patients to vividly visualize the situation or object that provokes a fear response. For instance, someone with claustrophobia may need to imagine being in a confined space.

Interoceptive exposure therapy involves exposing the patient to a harmless physical sensation to help them understand that this feeling does not signify danger.

Overall, exposure therapy can be a complex treatment avenue because, even with appropriate diagnosis and support, fear can lead patients to hesitate or avoid treatment.

In addition to the challenges associated with starting treatment, realistic exposure therapy may not always be feasible. For instance, in vivo exposure could be dangerous or inaccessible, while the traditional alternative, imaginal exposure, can be difficult to regulate.

Virtual Reality Exposure Therapy

Perhaps the most innovative type of exposure therapy is virtual reality exposure therapy (VRET). VRET leverages VR technology to create an entirely virtual, immersive experience, providing exposure therapy in the comfort of an office, home, or healthcare facility.

According to the APA, virtual reality therapy is “a form of in vivo exposure therapy in which clients are active participants in a three-dimensional computer-generated interactive environment that allows them a sense of actual involvement in scenarios related to their presenting problems.”

VRET is a form of exposure therapy that utilizes computers to create virtual settings, which users experience through virtual reality headsets or head-mounted displays (HMDs). Patients may find VRET to be more manageable and appealing compared to other types of exposure therapy.

An article in Campbell Systematic Reviews states, “The primary goal of VR is to substitute sensory experiences from the actual world and establish a sense of presence for the user in the virtual realm. To engage with the user in real-time, the VR system gathers data about the user’s position and head movements using sensors and input tools like a head tracking system or joystick.”

Psychological Assessments

According to research published in Dialogues in Clinical Neuroscience, virtual reality technology opens up a unique opportunity for deeper mental health evaluations by immersing patients in real-life scenarios.

While traditional psychological assessments have evolved since their inception, they fall short in accurately reflecting the daily experiences of patients. Limitations in live exposure lead to difficulties in precisely evaluating anxiety, PTSD, phobias, and other mental health issues, potentially affecting recommended treatment strategies.

Using VR assessments, mental health practitioners can glean insights into a patient’s psychiatric condition through virtual exposure. For instance, a study featured in the Annals of General Psychiatry found that both real and virtual images of food triggered similar reactions in people with eating disorders, indicating that VR might offer reliable assessments across various mental health issues.

Phobias

The initial demonstration of VRET’s effectiveness was reported by Barbara Rothbaum, PhD, in the American Journal of Psychiatry, observed to aid in overcoming a fear of heights.

A study in Cognitive Behavior Therapy examining VRET for individuals with public speaking anxiety concluded that VRET can be an essential therapeutic tool when implemented correctly and as part of the suitable care regimen.

Anxiety

As noted in Campbell Systematic Reviews, VRET has been investigated as an adjunctive therapy combined with traditional cognitive behavioral therapy for individuals with social anxiety disorder (SAD).

Research has further compared VRET as a standalone mental health intervention for anxiety, highlighting similar outcomes between VR therapy and conventional treatments.

Cognitive behavioral therapy (CBT) is the standard treatment for SAD and addresses other prevalent comorbidities such as depression. According to the systematic review and meta-analysis featured in Campbell, many individuals with SAD delay or avoid treatment due to high costs, extensive travel requirements, and other obstacles.

Post-Traumatic Stress Disorder

An article from the University of Central Florida (UCF) discusses the potential of VR exposure therapy in addressing post-traumatic stress disorder (PTSD). In addition to facilitating straightforward assessments, a publication by Albert Rizzo in the Annals of the New York Academy of Sciences examined the capacity of VRET to replicate combat experiences for soldiers who served in Iraq or Afghanistan.

Rizzo emphasizes that a customized approach to exposure therapy for combat-related PTSD could yield more patient information and assist in tailoring treatments to their specific experiences, enabling healthcare providers to evaluate PTSD symptoms and adjust medications or therapeutic strategies as needed.

Despite evidence from individual studies showing the efficacy of VR technology, a systematic review and meta-analysis published in the International Journal of Environmental Research and Public Health does not indicate a robust link between VRET and PTSD.

Findings suggest that gradually increasing stimuli throughout a session, rather than in response to the patient, diminishes the effectiveness of virtual reality exposure therapy for PTSD patients.

“Unfortunately, standard VRET involves increasing the intensity and frequency of trauma-related stimuli as the session continues, rather than tailoring this to the subject’s reactions. This approach may hinder full immersion for PTSD patients, as trauma-related stimuli are not presented with respect to their responses,” researchers noted in the article.

An alternative to the conventional progression of VRET is VR-based graded exposure therapy (VR-GET). VR-GET is a revised version of VRET treatment that observes a patient’s reactions during PTSD therapy. By assessing a patient’s physiological and emotional responses, the therapist can adjust treatment protocols accordingly.

Limitations

Although numerous potential benefits of VRET are recognized, there are also notable limitations. One significant barrier is the cost of VR technology, which can be prohibitive for patients, clinicians, or healthcare systems lacking the financial means for high-tech headsets and other necessary VR components.

The use of virtual reality (VR) in clinical practice faces limitations beyond financial costs for researchers and clinicians. The Dialogues in Clinical Neuroscience states, “The biggest challenge to implementing VR in clinical settings currently is the scarcity of evidence-based VR programs that can be easily purchased and utilized by clinicians and researchers. Several laboratories globally are creating their own software and conducting tests, but these solutions are not yet available for public purchase. The limited commercially available products developed by software firms have not been evaluated to determine their safety and effectiveness.”

Furthermore, these virtual solutions present challenges regarding the time, funding, and resources necessary for the upkeep and enhancement of software and hardware. The possibility of technological failures also poses a significant risk for patients with delicate conditions, like those with panic disorders.

Additionally, ethical issues relating to data security, privacy, confidentiality, and technological hurdles exist.

While VR is not a complete substitute for psychotherapy or other psychiatric treatments, it may offer an innovative approach to various conditions; however, further research, development, and incorporation into the healthcare system are vital for ensuring safe, effective, and affordable care.

VR therapy employs a computer-generated environment as a treatment tool. An individual might use it to practice skills, confront fears in a secure setting, or build confidence in social situations.

VR therapy is not intended to replace traditional treatments for mental health disorders. Instead, it is often utilized by clinicians as a supplementary intervention.

For instance, a therapist might integrate VR into cognitive behavioral therapy (CBT), enabling a client to practice new skills in a more controlled setting compared to real life.

Numerous studies indicate that virtual reality therapy can effectively manage various mental health issues, including anxiety, depression, post-traumatic stress disorder (PTSD), and phobias.

VR therapy leverages virtual environments and scenarios as therapeutic tools. A user may don a headset or utilize a device to immerse themselves in the virtual realm and engage with it.

VR technology allows for the simulation of a vast array of environments and situations, making it advantageous for creating scenarios that are difficult to replicate in the real world or that may be too intimidating or hazardous.

Therapists might employ VR to help clients navigate real-life challenges, revisit past experiences, or assist individuals in facing their fears in a controlled manner.

Researchers published the first study on VR therapy over 25 years ago, and as technology has advanced, interest in this therapeutic tool has grown.

How does VR therapy function?

VR therapy operates by providing individuals with the opportunity to enact, practice, or revisit situations in a safe environment. This approach may:

• teach skills
• alleviate fears
• enhance confidence
• assist in processing past events

By eliminating risks present in the real world, VR can render frightening experiences more manageable. For instance, someone with a phobia might not feel ready to confront it in reality, but engaging with a simulation in VR could help them gradually acclimate to the feared object and understand that it does not pose a threat.

In this manner, VR may facilitate a connection between therapy and real-life experiences.

What conditions could benefit from VR?

VR therapy was initially designed to address phobias, but over the years, therapists have experimented with it for a range of mental health disorders.

Phobias

Therapists can utilize VR for exposure therapy, which is a fundamental component of phobia treatment. This method involves slowly introducing a person to their fear in small, manageable increments, ensuring their consent.

While exposure therapy can occur without VR, it is sometimes challenging to achieve. For example, someone who fears flying cannot simply take a brief flight and progressively build their tolerance. Additionally, encountering fears like wild animals could expose individuals to danger.

VR broadens the opportunities for exposure therapy. A systematic review from 2022, which examined 18 studies, found that this method improved nearly all types of specific phobias addressed in the reviewed research, including animal phobias and fears related to blood or injections.

PTSD

Exposure therapy may also be beneficial for PTSD, but, as with phobias, controlled exposure to a traumatic event can be difficult and potentially unsafe.

Several studies indicate that VR therapy serves as an alternative. For example, a 2019 review and meta-analysis of nine prior studies compared the outcomes of VR exposure therapy with no treatment.

Compared to participants who received no therapy, those undergoing VR therapy reported a reduction in PTSD symptoms, with benefits persisting for at least three months following the conclusion of treatment.

Social and emotional skills

Individuals can practice a variety of social and emotional skills through VR therapy. For instance, they might rehearse addressing a conflict with their partner or request a raise from their supervisor. This enables them to safely experiment with new skills while under professional guidance.

Anxiety and depression

A review published in 2019 examined earlier studies and highlighted the potential utility of virtual reality (VR) in treating various aspects of anxiety and depression. It could:

• assist individuals in understanding mental health
• visualize cognitive-behavioral therapy (CBT) techniques
• promote self-compassion
• simulate therapies like gardening or animal-assisted therapy
• A scoping review from 2021 evaluated nine prior studies that integrated VR with CBT and concluded it could be beneficial for treating anxiety and depression.

What is the cost of VR therapy?

Within a therapist’s office, VR therapy typically costs about the same as conventional psychotherapy. Insurance may cover VR therapy in a clinician’s setting if the therapist is recognized by the insurance provider.

Some therapists provide clients with VR devices to use at home to complement their sessions, while certain companies offer home VR units for self-care. Clients might rent these devices weekly, depending on the type of device.

How can one find VR therapy?

To explore VR therapy, an individual needs to locate a licensed psychotherapist who has access to a VR device. Online search engines and directories for therapists may assist with this process.

VR therapy may be appropriate for individuals who:

• experience specific phobias or fears
• wish to practice particular skills
  are not prepared or able to confront certain situations in real life
• Numerous companies provide home VR therapy through an app, allowing individuals to progress at their own pace. However, this format is not equivalent to traditional psychotherapy and may lack some benefits.

When should one seek assistance?

Individuals should seek help when any mental health concern negatively impacts their relationships, quality of life, or well-being, especially if self-care has not alleviated their symptoms. This support could be accessed through a doctor or any qualified therapist, regardless of whether they offer VR therapy.

It is crucial to seek help if someone has thoughts of self-harm or suicide.

Virtual reality therapy utilizes virtual reality to recreate various scenarios. This technique can assist individuals in acquiring new skills and addressing their fears in a secure setting. Initially, therapists employed it to treat phobias, but it is now used for a wide array of conditions.

VR can create a controlled environment to tackle situations that might feel overwhelming or hazardous in the real world, which makes it valuable for exposure therapy. Nonetheless, as with any form of therapy, it is vital to receive care from a licensed and experienced provider.

What is the experience of virtual reality exposure therapy like?

You will spend time interacting with your therapist and discussing the events that led to your trauma. Following this, your therapist will establish the setting for your virtual reality exposure therapy (VRET). You may use a VR headset or enter a dimly lit room filled with screens that produce an immersive environment echoing what your trauma felt like. The experience can involve sights, sounds, smells, and vibrations to further replicate the traumatic event and emotional response. This setup aims to help you face the situations that induce fear and anxiety in a safe and monitored setting. You will review these immersive experiences with your therapist. Medications and coping skills training might also be integrated with your therapy.

Please note: VRET may induce dizziness or headaches, particularly for individuals with brain injuries.

What do patients say?

“It was an entirely different experience. I don’t recall having the physiological response… In just 13 weeks, I had completely transformed from who I had been for the last ten years. Before the treatment, 80-90% of my dreams were related to Iraq. Now I can’t even remember the last time I had one. I am living in a completely new way now.” – Jimmy Castellanos, Veteran, U.S. Marine Corps

“The layers … they just peel back and reveal your core. Initially, you resist, but eventually you break down and face it, and it’s truly incredible.” – Kevin Tergliafera, Veteran, Army National Guard

Why does virtual reality exposure therapy work?

When certain individuals undergo a traumatic event, they might react naturally, resulting in a heightened fear reaction to stimuli like sights, sounds, or other elements that trigger memories of that trauma. This can lead them to avoid circumstances that incorporate those triggers, such as the sound and sight of fireworks for someone with PTSD from military combat. By exposing oneself to these triggers in virtual reality, individuals can confront their fears in a controlled environment.

Similar to traditional prolonged exposure treatment, this practice enables one to learn coping mechanisms and reevaluate thoughts regarding the traumatic incident. Ultimately, this can lead to becoming increasingly desensitized to the triggers and coming to terms with the experience. Over time, the stress responses to these triggers can diminish significantly.

How substantial is the evidence?

Research indicates that VRET may be effective in alleviating PTSD symptoms. Numerous studies have demonstrated that VRET is associated with a reduction in symptom severity for both PTSD and depression, and that the effectiveness of symptom relief tends to increase with the number of VRET sessions attended. These improvements have also been shown to persist over time, as seen in 3-month and 6-month follow-up evaluations.

A randomized controlled trial confirmed these findings, indicating that patients undergoing VRET reported a decrease in symptoms related to PTSD, depression, and anger. This research concluded that VRET is most beneficial when combined with additional traditional treatment methods. Despite encouraging initial results, further research is required.

What are the characteristics of effective virtual reality exposure therapy?

Locate a licensed psychologist or another qualified therapist who has experience with prolonged exposure therapy, including VRET for PTSD and/or TBI. It is advantageous if they have experience dealing with your specific trauma source.

Advantages of VRET Compared to Traditional Exposure Therapy
There are various advantages to participating in virtual reality exposure therapy. Virtual reality acts as a link between a simulated stressful environment and the real world.

Here are some of the advantages of VRET therapy:

• It can be more cost-effective compared to real-life exposures: A virtual environment provides a budget-friendly and practical option, especially in situations where repeated real-life exposure may be too costly and dangerous, such as fears related to flying, heights, or wild animals.
• Participants experience a sense of control: VRET employs specialized equipment and devices that create a very realistic feeling experience; however, if it becomes too overwhelming, the session can be halted at any point.
• It can be beneficial for individuals lacking access to other treatment options: With the expansion of availability and quality of VRET, it may be possible to offer mental health care to patients who would otherwise have limited access to treatment.
• It often yields enduring results: Several studies indicate that VRET can effectively address anxiety, PTSD, and depression, with symptoms remaining low during follow-up appointments. Although these previous findings are promising, additional research is necessary.

Challenges & Obstacles to VRET Therapy

While VRET demonstrates effectiveness, it remains an emerging field with several challenges and obstacles to consider.

Here are some potential barriers to virtual reality exposure therapy you may encounter:

• There has been a gradual acceptance of VR technology as a viable therapy option: Clinicians often prefer face-to-face treatments. Even when professionals are trained in VR, they seldom utilize it, partly due to misconceptions about this exposure-based method.
• Access to and selection of VRET technology is restricted: VR software, equipment, and guidance on how to use them are not readily accessible to all therapists. Additionally, the broad array of materials can make it challenging for professionals to determine what is appropriate for themselves and their clients.
• There is insufficient training available for clinicians, making it difficult to find a licensed provider: Despite the increasing interest in VRET, there’s a lack of training opportunities for professionals wishing to incorporate it into their practice. Furthermore, they may need to refresh their training each time new software or products become available.
• More research is essential for understanding its effectiveness: Currently, VRET primarily addresses anxiety-related disorders such as PTSD and specific phobias. However, with the growing efficacy and popularity of VRET, more data is required to extend its benefits to other mental health conditions.

What Equipment Is Typically Utilized in Virtual Reality Therapy?

To partake in virtual reality exposure therapy, a provider employs programmed computers, immersive devices, and artificially created settings that replicate reality through a simulated experience. The individual undergoing virtual reality exposure therapy is fitted with a headset that grants access to the virtual environment. Contemporary virtual reality equipment has been adapted for smartphones, enabling the use of gyroscopes and motion sensors to monitor head, body, and hand positions while also tracking subjective units of distress.

The equipment used during a virtual reality exposure therapy session is generally supplied by the therapist, although some individuals seeking this treatment may purchase their own headsets or goggles either through their therapist or online, with prices ranging from less than $50 to several hundred dollars.

Virtual reality exposure therapy is suitable for various populations and ages. Besides adults, children and teenagers can be great candidates for innovative methods to develop healthy coping strategies. Research investigating the effectiveness of virtual reality exposure therapy for adolescents aged 13 to 16 who faced public speaking fears due to social anxiety showed positive outcomes in helping them manage their symptoms.

Beyond its common applications, virtual reality is also being explored for treating sleep-wake disorders, enhancing sports performance, and addressing stress and test anxiety.

Virtual reality has been widely employed as a prolonged exposure technique for treating PTSD in military personnel. Significant funding from military sources has facilitated numerous studies to assess the effectiveness of this method. With virtual reality exposure therapy, providers can create an immersive, 360-degree interactive computer-simulated environment.

A meta-analysis that reviewed 14 studies involving military populations with PTSD demonstrated the high efficacy of virtual reality exposure therapy. Additionally, this therapy has been utilized in treating PTSD among military personnel through a program called Virtual Iraq. In this approach, soldiers use a head-mounted display and a gamepad to navigate a simulated Iraqi environment while traveling in a Humvee.

Systematic exposure to these feared stimuli and settings aims to alleviate anxiety and traumatic stress symptoms. Initial findings among the first group treated revealed significant reductions in PTSD symptoms, with 75% of participants no longer meeting the DSM-V criteria for the diagnosis. Another investigation using the Virtual Iraq framework reported approximately a fifty percent reduction in PTSD symptoms among veterans diagnosed with the condition.

Virtual reality exposure therapy serves as a practical exposure therapy method for anxiety disorders, with strong empirical support. Research findings uphold the use of VRET to address anxiety and phobia symptoms. This technology-based treatment approach enables clients to cope with anxiety by facing their fears through gradual or repeated exposure.

The ultimate aim is to alter thought patterns, behaviors, and reactions that hinder daily functioning. The feared stimuli can differ from individual to individual, but may include living creatures, objects, situations, activities, thoughts, mental images, physical sensations, or experiences. Encountering these feared stimuli can lead to the extinction of the fear response, which is beneficial compared to other forms of exposure therapy (e.g., in vivo exposure), as VRET allows access to the most feared cues.

VRET is increasingly employed for specific phobias, such as an intense fear of animals. The virtual settings can replicate feared animals or insects like spiders, snakes, or roaches. Recently, it has also been adapted for treating fear of public speaking, fear of heights, addiction, bullying, claustrophobia, depression, and eating disorders.

What contributes to the success of virtual reality exposure therapy? Virtual reality uses visual and often physical simulations to evoke sensory responses similar to real-life experiences. By integrating VR with various techniques, VRET enables individuals to confront and receive feedback in a secure environment, facilitating processing and diminishing established responses. Moreover, it allows individuals to gradually approach fears that might be harder to tackle in the real world. Ultimately, VRET provides a safe exposure experience, encouraging individuals to challenge their reactions, process stimuli, and alleviate symptoms, ultimately enabling them to engage more in real-life activities.

The effectiveness of exposure therapy, especially when combining multiple theories, can be explained through habituation, extinction, emotional processing, and self-efficacy theories. Each theory or a combination thereof can elucidate the success of virtual reality exposure therapy:

• Habituation theory is utilized by repeatedly presenting a stimulus (for instance, an individual who has been attacked in a park and now avoids parks utilizes VR to be immersed in a virtual “park” environment) to lessen anxiety and boost familiarity.
• Extinction theory is employed to diminish the conditioned response (such as fear, avoidance, anxiety) by weakening the reinforcement of an unconditioned stimulus (the experience of being attacked in the park); this association is weakened through repeated exposure to a conditioned stimulus (the park) without the occurrence of the unconditioned stimulus.
• Emotional processing is implemented by repeatedly facing a stimulus (the park) to confront the response (panic, anxiety) and the unhealthy beliefs (for example, “I’m too weak to defend myself, I’m foolish for not anticipating that”) that were initially ingrained in one’s memory.
• Self-efficacy is fostered by acquiring techniques to handle or master a fear-inducing situation, which affects a fear or anxiety response; by mastering these skills, one acknowledges their ability to manage a frightening circumstance and can use this knowledge with similar stimuli.

What to Expect at Your First Session

Prior to commencing virtual reality exposure therapy, the therapist will conduct an initial consultation to evaluate if a prospective client is suitable before starting. Once an individual is considered eligible for VRET, the therapist will administer a biopsychosocial assessment during the first session, allowing them to gather comprehensive information about their client and their therapy objectives prior to entering the treatment phase.

After this assessment, the next step will involve treatment planning, which includes providing fundamental education about the specifics, establishing expectations, and allowing the client an opportunity to ask questions or voice any concerns. It’s important to note that each therapist may have different operating procedures, but they will typically include many of the standard processes discussed. The treatment process will then commence and can occur either in person or through virtual means.

What Is a Typical VRET Session Like?

During the exposure therapy session, where the therapist may address a specific phobia or trauma, the client will encounter exposure to feared stimuli or environments. By using VR equipment such as a headset or goggles, the client will have direct access to the simulated or artificial environment while gradually increasing the intensity of their exposure to the stimuli.

Thanks to the flexibility in regulating the simulated setting, the individual undergoing treatment should recognize that the therapist can lessen or eliminate exposure to the fear at any moment. With the inclusion of biofeedback equipment, physiological sensations can be monitored and recorded using sensors between treatments. If the session is being conducted virtually, all that is required are the headset or goggles and access to a smartphone since the virtual environment is navigated through an app on the individual’s phone, which the provider controls.

VRET Examples

While the fundamental procedures of VRET will be consistent for everyone, there may be some differences based on the client’s experiences and the specific VRET equipment being utilized.

Here are a few instances of VRET in practice:

VRET for a Phobia

Dan, a 31-year-old man, recently purchased a house and soon discovered it was infested with spiders. Dan suffers from a severe phobia of spiders, often resulting in panic attacks. He moved in with his parents after scheduling pest control for his new home but has struggled to go back and even see how the house looks due to his fear and anxiety surrounding the spiders.

Dan consults a VRET therapist to address this issue, as he wishes to return to his new residence. He and his therapist begin with an exposure hierarchy, listing his fears to evaluate comfortability. They decide on habituation and self-efficacy techniques.

In each session, he wears VR goggles and biofeedback sensors because of his panic attacks and observes virtual spiders approaching him. He engages in this for an extended duration in each session while his therapist monitors his sensors. Following each exposure, they discuss the emotions that arise, partake in educational activities and coping practice, and occasionally repeat the exposure. Eventually, Dan feels comfortable enough to visit his home and, after 2 months, succeeds in moving back in with ongoing therapy.

VRET for PTSD

Jane, a 29-year-old woman, has recently returned from her third year-long deployment in an active combat zone. Although she managed to adjust well after her first return, she has recently started experiencing symptoms of post-traumatic stress disorder (PTSD). During her debriefing, she frequently discussed her symptoms and continues to face flashbacks, hypervigilance, nightmares, irritable behavior, and challenges at work and with her family, even 6 months later as a result.

Jane began working with a VRET therapist knowledgeable in military matters to start addressing some of her symptoms, hoping to reclaim her life. Loud noises triggered her significantly, often causing reactions that others saw as exaggerated. Together, Jane and her therapist commenced sessions using Virtual Iraq VRET, employing a head-mounted display and game pad, gradually increasing the duration while identifying specific triggers and applying coping strategies and skills as they arose.

Over time, Jane managed to return to her job and developed an action plan with her employers and family for managing loud noises and particularly disruptive flashbacks.

VRET for Social Anxiety

Taylor, a 19-year-old, was frequently labeled as shy during high school. However, Taylor struggled significantly in crowded settings, never took part in talent shows or groups that required extensive social interaction, and often found socializing challenging. The school counselor suggested that Taylor might be experiencing social anxiety disorder (SAD), but did not facilitate any treatment.

After a year at college, Taylor continued to face many of the same challenges and found it difficult to connect with others, but desired friendships and connection while attending school. A therapist subsequently diagnosed Taylor with social anxiety following a comprehensive evaluation and recommended VRET. In therapy sessions, Taylor was engaged in social interactions and practiced communicating with several people for longer periods, using a headset and biofeedback sensors. Taylor was also encouraged to confront or challenge negative thoughts such as “I’m an idiot” that arose during interactions, both in real life and within the VR environment.

Eventually, Taylor formed a small circle of local friends as well as some online friends and started participating more actively in classes.

Who Can Provide VRET?

There is specialized training available that equips providers with the necessary skills for delivering virtual reality exposure therapy. Nevertheless, there are currently no specific certifications mandated for offering this type of treatment. Any mental health professional interested in this method can undergo training through organizations like Psious, which is a leading entity supplying VR equipment tailored for treating various mental health disorders.

Donna Davis, Ph.D., who directs the Oregon Reality Lab in Portland, Oregon, specializes in virtual reality therapy (VRT). She clarifies that VRT takes place in a computer-generated or 3-D environment and is entirely distinct from teletherapy. While teletherapy involves virtual talk therapy (like through Zoom), VRT focuses on utilizing a virtual setting, such as a computer game or headset. It is crucial to emphasize that for it to qualify as therapy, a licensed therapist must be present. Programs or videos aimed at relaxation or enhancing meditation do not qualify as VRT since there is no therapist involved.

A specific kind of VRT is known as virtual reality exposure therapy (VRET), which immerses individuals in a highly realistic 3-D environment. This is often accomplished using a headset, but not always. For instance, if someone has a fear of heights, the 3-D setting might feature a glass elevator to aid them in confronting their fear. VRET is also employed to support individuals with various phobias, as well as those experiencing post-traumatic stress disorder (PTSD) or victims of violence.

However, VRT does not always reach such an immersive level. Dr. Davis mentions that another version of VRT involves conversing with a therapist while assuming an avatar’s identity in a computer-generated setting. For example, Dr. Davis has been involved with a virtual reality support group for individuals with Parkinson’s disease on the online platform Second Life, where members create 3-D characters in an alternate universe. The group has been “meeting” consistently for over a decade. “Participants in the group develop an avatar, which allows them to feel more secure when opening up, as their actual physical identity remains hidden,” she states.

As VRT remains relatively new, there are fewer therapists trained in its application compared to more traditional therapy methods. Consequently, access can be challenging. Dr. Davis recommends searching online for clinical therapists in your area to determine whether they have been trained in VRT or VRET. Another useful resource is Virtual Reality International, which maintains a database of VRT therapists.

How Effective Is Virtual Reality Therapy?

Lucy Dunning, a licensed professional counselor in Marietta, Georgia, who incorporates VRET into her practice, notes that since the concept is still emerging, data regarding its long-term effectiveness is being developed. However, initial research indicates encouraging outcomes. “It has particularly demonstrated success for individuals with PTSD, anxiety, and chronic pain,” she remarks.

Reports indicate that virtual reality therapy in the form of VRET has a success rate ranging from 66% to 90% for individuals with PTSD when combined with cognitive behavioral therapy (CBT), based on 2022 research published in JMIR Serious Games. Additionally, it has been shown to significantly alleviate pain as an alternative to medications. A study published in the Annals of Behavioral Medicine found that burn victims, when placed in a snowy environment where they could interact with snowmen and throw snowballs, experienced a reduction in their physical pain by 35% to 50%. Scientific studies have also shown success in overcoming spider phobias and positive results for treating individuals with eating disorders.

Most current research on VRT is concentrated on VRET, and less is known about the effectiveness of therapy involving avatars in a virtual world. One study published in Frontiers in Psychiatry found that using CBT in a virtual reality context effectively treats individuals dealing with depression, who may hesitate to pursue conventional therapy. Another article in JMIR Mental Health suggests that VRT could serve as an alternative treatment method to in-person therapy for individuals experiencing social anxiety.

Are There Risks Associated with Virtual Reality Therapy?

Virtual reality therapy has several beneficial aspects, but it also comes with downsides. Although the virtual component might enhance accessibility, using it from home necessitates a computer or smart device along with a reliable Internet connection, which may not be readily available for individuals in underprivileged areas. Some people who lack technical skills might struggle to navigate VRT, and since VRT is still fairly new, finding a qualified provider can be challenging.

As with any form of therapy, the therapist plays a critical role in determining the treatment’s effectiveness, according to Dr. Davis. Especially with Virtual Reality Exposure Therapy (VRET) utilizing realistic scenarios, simulations that are too realistic could possibly cause distress for participants if they are not supported by a skilled therapist.

Another important factor is the therapist’s ability to assist the individual if an issue arises. “If the therapist is located far away, or if the person receiving counseling is interacting anonymously, this introduces significant ethical concerns and issues,” she states. “In any therapy setting, safeguarding the patient is essential. Anonymity can pose a substantial risk.” As with many new technologies, ethical considerations will likely need to be addressed as this treatment becomes more common.

The Prospects for Virtual Reality Therapy

Dr. Davis and Dunning are enthusiastic about the potential for VRT. “The future looks promising as technology evolves to become more advanced, affordable, and accessible,” Dr. Davis notes. Dunning concurs, suggesting that its usage will expand as additional VRT platforms emerge.

If you are dealing with anxiety, depression, PTSD, chronic pain, or wish to overcome a phobia and have an interest in technology and creativity, VRT might be a suitable option for you.

It is crucial to consult with a provider who is specifically trained in VRT. “Take the time to investigate which clinical practices exist in your area and whether the providers possess training in VRT,” advises Dr. Davis. Before deciding to proceed, ensure you know who is facilitating the sessions. Unlike clients attending therapy, the identity of the therapist should not remain anonymous so you can research their qualifications and confirm that they are properly trained to assist you effectively.

The expense associated with VRT varies based on the provider, the individual’s health insurance, and any required equipment (such as a headset) for at-home use. Some VRT sessions may be pricier than other types of therapy when considering the costs for equipment, as noted by the mental health non-profit Panic Anxiety Community Support. Thankfully, prices for VRT software are declining, making this therapy increasingly affordable.

Therapy through virtual reality is no longer a concept of the future; it is occurring presently. As VRT is still in its early stages, there is no existing data regarding how many people currently utilize it, yet as more clinicians gain training and research increases, accessibility will grow. “There is tremendous potential for development and learning,” states Dr. Davis.