Using VR in psychiatric care: ‘This time, we have the technology’

Albert Rizzo – who has been immersed in the world of clinical VR for more than two decades – says that he was a “victim” of the inappropriate hype around the technology that erupted in the 1990s, which made him particularly cautious about claims that VR is ripe for mass adoption.

“[During] the first hype cycle of VR, the technology sucked. The vision was sound but the execution was impossible. Now we still have a lot of hype, but this time we have the technology,” he told E&T, speaking at Laval Virtual 2019, the mixed-reality conference.

VR has suffered cycles of hype and deflation as people puzzle over which sectors it has the potential to transform: could it replace the whiteboard as the principle tool in education or is it merely the next platform for gamers? Will it be strictly limited to the world of manual labour or will it fuel a new wave of porn addiction? Despite advances in technology and falling costs, VR has not yet ‘disrupted’ a sector in the way that was promised. The headsets were always too expensive, the graphics too clunky, the need unconvincing.

However, Rizzo believes VR is ready for adoption in mental healthcare. This is “theoretically informed, scientifically supported and now pragmatically deliverable, with advances in lower cost and high-fidelity equipment and easier to use software”. Key to psychiatric care being a good starting point for mixed-reality clinical care is that VR-based psychiatric treatments are not a great step into the unknown: they are based on treatments known to work in the ‘real world’. It is unsurprising then, that study after study (including those conducted by Rizzo’s own group) has shown that treatment using VR simulations can be at least as effective as standard treatments.

Exposure therapy was the first area of mental healthcare into which VR was introduced and shown to be effective. Exposure therapy was developed in South Africa in the 1950s and is a standard treatment for phobias such as fear of flying and agoraphobia. Patients are exposed to situations which trigger panic in a safe and controlled setting, gradually intensifying exposure as the patient learns to manage their fear. Exposure therapy frequently involves the patient using their imagination and looking at photographs and videos to confront their fears at earlier stages of exposure; using a VR headset, a patient can be immersed in realistic fear-inducing situations but which they know to be simulations.

These sorts of simulations are now being expanded in trials to treat patients with more complex conditions, such as PTSD and substance addiction, sometimes in parallel with pharmaceutical approaches when necessary. Rizzo and his colleagues have developed an interactive VR program called Bravemind, which is intended to help soldiers cope with post-traumatic stress (PTS). Bravemind consists of virtual scenes mimicking traumatic military combat (including violent and chaotic scenes in “Middle Eastern themed” cities and desert roads) and uses directional 3D audio, vibrations and smells for deeper immersion. These scenes can be controlled by a therapist as they help the patient process the emotions associated with their trauma. Bravemind – which has been shown to meaningfully reduce PTS symptoms – is already found at over 60 sites.

According to Rizzo, VR-based therapy like this is comparable with traditional therapy in terms of inducing permanent changes in thought and behaviour patterns.

Some may question why it is worth introducing VR into clinical mental healthcare if it is comparable to standard treatments. Rizzo says that his work in VR fills a gap where there is currently an insufficient number of clinicians available to look after the number of patients in need, whilst also improving some experiences not overseen by a clinician, such as initial surveys to measure levels of depression and anxiety in a new patient or providing continuous care between therapy sessions. For instance, one of his group’s projects (which eventually was not funded) proposed sending VR headsets home with patients to use between therapy sessions. These headsets would be loaded with some of the content they needed to look over in the days between sessions, but presented more appealingly than plain printed pages of text.

“You send manuals home with people, they leave it on their counter and then half an hour before their next session, they [remember it],” Rizzo said.

Another one of Rizzo’s projects involved developing a virtual human coach to support USC students on long waiting lists to begin counselling. This virtual coach provided basic support to the students, such as sleep hygiene, introducing cognitive behavioural therapy principles, as well as helping them get used to speaking to a person about sensitive issues. Rizzo said that this could break down one of many barriers to accessing clinical care: unwillingness to share painful and shameful secrets with another person.

“We built a ton of content dealing with anxiety, depression, loneliness, determining whether you’ve been sexually assaulted and how to deal with it, and how to have all these private interactions. We found people tend to be more honest and revealing when it’s a piece of software than when talking to a real person,” said Rizzo. “The introduction of the virtual human adds an element that’s a stepping stone towards practising what you’re going to do with a real human, but in a safe place so you get used to talking about your issues in a safe place where no-one’s judging you.”

Rizzo is aware that some cynical healthcare providers may see clinical VR technology as a means of increasing investment in mental health services and staff. He emphasised that researchers and doctors had to practice great caution before proposing technological replacements for standard clinical care.  Already, he says, there are issues with some people self-diagnosing their conditions and pursuing the wrong treatments, so it is important for trained clinicians to oversee psychiatric care, particularly in diagnosis and particularly when working with complex conditions (even when for VR-based therapy).

“As a care provider, as a clinician, as a psychologist, a medical doctor, you have these standards and they have to supersede the financial motivations,” he said. “We have to be scientific and we have to be ethical and those are things that professionals hold as values: proof that something works and it is being ethically, soundly delivered to people to reduce harm. That’s the Hippocratic Oath and it has to be the first principle here.”

“Of course, if I can develop something that reduces the amount of time I need to be with a [patient] and saves money, but is shown by the research to be safe and equivalently effective or close enough, then I’m all for that.”

Rizzo proposes that one of the ways in which VR may prove most beneficial is in providing care for those whose lives are not disrupted by mental illness, but who would nevertheless benefit from exploring further the techniques practised in therapy, such as mindfulness. For instance, he mentions that the USC is interested in using the application which he and his colleagues built to support students waiting for counselling as a “general wellness application”.

“[This is] not to replace intensive clinical care with a live provider, but as a way to generally improve everyday wellness,” he said. “If somebody in the course of doing this becomes aware that they have really got some big issues, then the system can show them how they can seek care and what that care would involve.

“It won’t have to replace people, but it will make these kinds of activities more available and amplify the access to care that I think many people don’t have.”

According to Rizzo, the next major obstacle is getting psychiatrists, psychologists and other mental health professionals to adopt this technology in a way which complements their skills. To complicate matters, there are concerns about technological replacement even in such a human-centric field as medicine.

“It’s a big issue. With AI and robotics we accept that a lot of factory jobs are going to go away, we accept that maybe autonomous cars and trucks are going to eliminate cab drivers and truck drivers, but eliminating psychologists, that’s like: ‘Oh no!’” Rizzo said.

“I think we have to be very careful because I think there’s something about the human element brought that needs to be preserved. I think it’ll be the most contentious issue in the next ten years in psychological clinical care: how much of that can be offloaded to technology?”