Exploring Virtual Reality Exposure Therapy in Mental Healthcare

Exposure Therapy

Exposure therapy has uses in treating multiple mental health conditions, including phobias, panic disorders, social anxiety, generalized anxiety, obsessive–compulsive disorder (OCD), and PTSD.

According to the American Psychological Association (APA), exposure therapy has four main categories: in vivo exposure, imaginal exposure, interoceptive exposure, and virtual reality exposure.

In vivo exposure refers to an in-person, real-life interaction with a particular situation or activity that may result in the condition’s symptoms. One example is direct exposure to specific phobias. A person with acrophobia, a fear of heights, may be taken on a rollercoaster or up a mountain. Someone with a fear of public speaking may be asked to deliver a speech.

Imaginal exposure requires the patient to vividly imagine the thing or situation that causes a fear response. Someone with claustrophobia might have to imagine being in a small room.

Interoceptive exposure therapy is when a patient is made to feel a harmless physical sensation to reassure them that this feeling does not mean they are in danger.

In general, exposure therapy can be a complicated treatment route because — even with the proper diagnosis and support — fear may cause patients to refuse or delay treatment.

In addition to difficulty initiating treatment, exposure therapy that reflects the real-life stimulus may not be an option. For example, in vivo exposure may be dangerous or inaccessible. The standard alternative, imaginal exposure, can be challenging to control.

Virtual Reality Exposure Therapy

Arguably the newest and most cutting-edge type of exposure therapy is virtual reality exposure therapy (VRET). VRET uses VR technology, an entirely virtual, immersive experience, to provide exposure therapy in the comfort of an office, home, or healthcare facility.

The APA defines virtual reality therapy as “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 type of exposure treatment that uses computers to generate virtual environments, which are presented to the user via virtual reality glasses or a head-mounted display (HMD). VRET may be easier and more acceptable to patients than other forms of exposure therapy.

According to an article in Campbell Systematic Reviews, “The overall aim of VR is to replace sensory input from the real world and to create a presence of the user in the virtual world. To interact with the user in real-time, the VR system collects information about the user’s position and (head) movements via sensors and input devices like a head tracking system or a joystick.”

Psychological Assessments

According to an article published in Dialogues in Clinical Neuroscience, virtual reality technology presents a unique opportunity to conduct more in-depth mental health assessments by immersing patients in real-life situations.

While traditional psychological assessments have advanced since their initial development, they cannot accurately account for the day-to-day experiences of the patient. With limitations to in vivo exposure, precise evaluations of anxiety, PTSD, phobias, and other psychiatric conditions are limited, potentially altering suggested treatment options.

With VR assessments, mental health professionals can gain insight into the patient’s psychiatric condition through virtual exposure. For example, a study published in the Annals of General Psychiatry determined that real and virtual photos of food elicited similar responses in individuals with eating disorders, suggesting that VR may provide accurate assessments across other mental health conditions.

Phobias

The first demonstration of the efficacy of VRET was published by Barbara Rothbaum, PhD, in the American Journal of Psychiatry, noting that VRET was beneficial for helping overcome a fear of heights.

A study published in Cognitive Behavior Therapy analyzing the use of VRET for patients with public speaking anxiety determined that VRET can be a critical therapy tool when used correctly and under the appropriate care routine.

Anxiety

According to Campbell Systematic Reviews, VRET has been explored as an adjunct therapy — combined with traditional cognitive behavioral therapy — for people with social anxiety disorder (SAD).

Studies have also compared VRET as an independent mental health treatment for anxiety, noting comparable results between VR therapy and traditional treatments.

The standard treatment for SAD is cognitive behavioral therapy (CBT), addressing other common comorbidities such as depression. According to the systematic review and meta-analysis published in Campbell, many people with SAD avoid or delay treatment due to high treatment costs, long travel distances, and other barriers.

Post-Traumatic Stress Disorder

An article by the University of Central Florida (UCF) highlights the implications of VR exposure therapy in treating post-traumatic stress disorder (PTSD). In addition to providing an option for easy assessments, an article published by Albert Rizzo in the Annals of the New York Academy of Sciences assessed the ability of VRET to mimic war experiences for soldiers who were in Iraq or Afghanistan.

According to Rizzo, a personalized or tailored approach to exposure therapy for combat-related PTSD could provide additional patient data and help tailor treatments to their experiences, allowing healthcare professionals to assess PTSD symptoms and adjust medication, psychotherapy, or treatment accordingly.

Despite data from individual studies demonstrating the utility of VR technology, a systematic review and meta-analysis published in the International Journal of Environmental Research and Public Health does not suggest a strong enough link between VRET and PTSD.

Data suggests that gradually increasing stimuli depending on the session instead of the patient’s response reduces the efficacy of virtual reality exposure therapy for PTSD patients.

“Unfortunately, in conventional VRET, the intensity and frequency of trauma-related stimuli are graded as the training session progresses, not according to the subject’s response. However, this method has less chance of fully immersing patients with PTSD as trauma-related stimuli are not presented in consideration of the patient’s response to them,” stated researchers in the article.

An alternative proposed to the standard progression of VRET is VR-based graded exposure therapy (VR-GET). VR-GET is a modified version of VRET interventions that monitors a patient’s response to VRET during the treatment of PTSD. By analyzing a patient’s physiological and emotional response, the therapist in charge of treatment can alter treatment protocols accordingly.

Limitations

Although there are many perceived or hypothesized benefits of VRET, there are also some associated limitations. For example, the cost of VR technology can pose a significant barrier to patients, clinicians, or healthcare systems that may be unable to afford high-tech headsets and other components required for VR therapy.

Beyond costs, access is limited for researchers and clinicians. According to the Dialogues in Clinical Neuroscience, “The biggest limiting factor to the implementation of VR into clinical practice at present is the lack of evidence-based VR programs that can be bought off the shelf and used by clinicians and researchers. A number of labs around the world are developing their own software packages and testing them, but they are not yet commercially available. The few commercially available products developed by software companies have not been tested to show whether they are safe and effective.”

Other challenges these virtual solutions pose include the time, money, and resources required to maintain and update software and hardware. Additionally, the risk of a technological malfunction can pose a significant threat to patients with sensitive conditions such as panic disorders.

Finally, there are ethical concerns about data safety, privacy, confidentiality, and technological challenges.

While virtual reality is a fool-proof alternative to psychotherapy or other psychiatric interventions, the tool may provide a novel approach to multiple conditions; however, additional research, development, and integration into the healthcare system are necessary for safe, effective, and affordable care.