‘After, I feel ecstatic and emotional’: could virtual reality replace therapy?

If youve got acrophobia, paranoia, anxiety of flying, PTSD, even depression, software could soon be the solution

Leslie Channell admits he’s not a typical case for treatment. Channell, known to everybody as Chann, is a registered pilot who served 24 years in the army working on Apache helicopters. Chann also happens to be scared of heights. He doesn’t mind flying planes or sitting on the side of the Apache with the door open; he’s just frightens of going up two or three floors of a building or driving over a bridge.

Chann is nervous; his speech is fast. He says he’s sweating. We fulfill at a trendy startup in Oxford, where he is about to undergo virtual-reality therapy for his phobia( although the word “virtual-reality” therapy is controversial: some say the VR is just a tool for the therapy; others argue that the virtual reality is the therapy itself ). Psychologists are now trialling VR for all kinds of conditions, from phobias to pain management to post-traumatic stress ailment( PTSD ).

There are two other people in the room. Cognitive-behavioural therapist Polly Haselton sits behind a curving computer screen watching Chann, occasionally asking questions. Daniel Freeman, professor of clinical psychology at the University of Oxford and one of the world’s pioneers in this field, watches Chann’s every movement. Freeman explains there are three common fears of heights: that you will fall; that what you are standing on will give way; or that you will leap, which is known as” the call of the void “. Chann’s dread is of falling.

A The virtual reality therapy program that guides patients through their fear of heights

A Photographs: Nowican/ Oxford VR

He straps on his virtual-reality headset( also known as a head-mounted display, or HMD ). Inside the headset, he will find himself fully immersed in a three-dimensional world. Today, he is going to level four of a 10 -storey building in New York to rescue a kitten stranded on a branch of an indoor tree.

Chann has to use a lever to pushing himself on to a small platform towards the cat. He is a stocky, tough-looking human in his late 50 s. But he’s not looking tough any more. His voice is rising, and he’s shaking. He edges forward along the virtual branch. In real life, his feet also move gingerly- then come to a sudden stop. His breathing becomes louder and more staccato.

“You’re doing really well,” Haselton says.

” You don’t know how difficult this is ,” Chann gasps.” Come here, cat .” Then he stops.” Nah, can’t get it. Aaaagh. No! Gotta come back .”

He starts again, cautiously edging forward.” Yes. Yes. Yes! No, stop Chann. Yes! Yes !” His yeses are urgent, desperate. He makes a grab for the kitten, and returns it to virtual safety.

Task complete. He takes his headset off, talking even faster.” My anxiety levels were way high. Super high .”

” We’re talking nine out of 10, 10 out of 10 ?” Freeman asks calmly.

” Yeah. I really didn’t want to be there. I had to think I was in a room in Oxford.’ You’re not here, it’s all OK, do it .'”

Chann is one of a dozen people currently testing this software.( Next month, the trial is being extended to 100 people .) Already, he says, it has made a difference to his life.” Yesterday, I went on a rollercoaster with my daughter. I had never gone on one before. Not the big ones, the smaller ones, but still …” He’s spent only around 20 minutes in the virtual world today, but he is depleted.” I was worried about coming here, and I’ve done it, and I’m buzzing. Elated .” He pauses, trying to catch his breath.” But I know in my heart of hearts, if there was a real cat on level four, I would not be going out and get it. Polly asked a question, what if it was a little newborn? That would change the dynamics .”

Freeman has been working with VR for 16 years. What he loves about this therapy is its simplicity.” There are very few conditions VR can’t help ,” he says,” because, in the end, every mental health problem is about dealing with a problem in the real world, and VR can make that troubling situation for you. It gives you a chance to coach-and-four people in other ways of responding. The people I see are anxious or depressed, or worried about people assaulting them, and what they’ve done in their life is retired from the world. With VR, you can get people to try stuff they haven’t done for years- come in lifts, to shopping mall, then they realise they can do it out in the real world .”

Acrophobia, or the fear of heights, is just the start, Freeman says. He has already developed VR programs that treat people with paranoia- for example, placing them in virtual libraries, lifts or on tube develops with strangers eyeballing them. In a Medical Research Council-funded study, he used VR with 30 patients to help them re-learn that they are safe around other people.

” The outcomes were remarkable. From just 30 minutes in VR, there were large reductions in paranoia. Immediately afterwards, more than half the patients no longer had severe paranoia. Importantly, the benefits transferred to the real world. It wasn’t a definitive examine. It was small and short-term, but research results do indicate great potential .” The program will initially be used in NHS mental health services with a staff member present, but Freeman believes that, ultimately, it could be available commercially.

Nearly two million people attempted advice for mental health issues in 2015, according to the Health and Social Care Information Centre- up from 1.2 million in 2010. Meanwhile, the number of mental health nurses fell by virtually 15% from 45,384 in 2010 to 38,774 in July 2016, according to a written parliamentary answer from Philip Dunne, the health minister. The British Medical Association recently revealed that in 2016 -1 7, 5,876 adult patients with mental health conditions were referred to another health trust for therapy, with some patients being sent 600 miles away to Scotland. Against this backdrop, virtual reality is the great hope for many mental health professionals. Some psychologists believe they are on the brink of a VR revolution. Then again, they were saying the same thing a quarter of a century ago.

Barbara Rothbaum‘s office in Atlanta, Georgia, is shut due to the impending arrival of Hurricane Irma. In between energy cuts, I manage to speak to her at her home. Rothbaum is a professor in psychiatry, a clinical psychologist at Emory University, and the founding mother of exposure therapy employing virtual reality.” We published the very first analyse employing VR to treat a psychological and psychiatric disorder back in 1995 ,” she tells me. Again, it was to treat acrophobia, and research results amazed Rothbaum.” Seven out of 10 people who got the virtual reality reported putting themselves in real-life height situations afterwards .” That was when they thought they were on to something big.” We used to say:’ We’re on the cutting edge of the lunatic fringe .’ That was our line at the time .” She laughs.

After acrophobia, Rothbaum developed a VR program for anxiety of flying. This was even more effective, because traditional exposure therapy( paying for yourself and a therapist to travelling on a plane) is time-consuming and costly.” I can do all that in my 45 – to 50 -minute therapy session, with ultimate control. So if I know they’re not ready for turbulence, I can guarantee there won’t be turbulence .”

Rothbaum then went on to do pioneering work with Iraq and Afghanistan war veterans suffering from PTSD. Before VR, veterans were confined to imaginal therapy- basically, shutting your eyes and thinking yourself back to the original situation. But now Rothbaum could recreate it for them in a controlled environment.” With PTSD, especially in military folk, they are very avoidant emotionally. With VR, it’s harder to avoid, because it is such a potent stimulus .”

Early on in her VR career, a public-private partnership between Emory University and the Georgia Institute of Technology insisted Rothbaum and her colleagues form a corporation and patent their software. The result was a company, Virtually Better, that designs environments for fellow clinicians to use.” That is my conflict of interest ,” Rothbaum says. Whoever she speaks to, she instantly declares it. Does it worry her that she is responsible for the research showing how effective her own VR products are?” It has done, over the years ,” she says.” One of the ways I manage it is, I disclose, disclose, disclose .”

Rothbaum is not alone. VR therapy is a small, niche world. Read the scientific papers, and the same names crop up again and again. And most of these academics are now also operating commercial companies. As traditional funds dry up for universities, people such as Rothbaum are increasingly reliant on business- often their own business- for support in their research.

As it happens, Rothbaum says, she absence the cut-throat instincts to be a good businesswoman.” A criticism of Virtually Better was that it was operate more like an academic department than a business. We knew how to write grants so we’d write small business grants and enjoy collaborating rather than competing. I thought it was an interesting route to do exposure therapy and wasn’t very mercenary about it .”

Has she ever utilized VR to treat her own fears?” No. My fear early on was that somebody was going to make a lot of fund, and it wasn’t going to be us. Actually, that is probably still going to come true. But I’ve adapted to that; it’s all right .” She’s still not rich?” Oh no , not by a long shot , no .”

Despite research showing its efficacy, the VR therapy revolution did not take off in the 1990 s or the noughties. This time around, though, it looks as if it might. Mel Slater, a professor of virtual environments, reveals me why. We gratify in the London HQ of Digital Catapult, a government initiative to promote the digital economy. Slater hands me the headset used in the virtual psychotherapy sessions he is developing.” The VR world burst open in 2013 when this Oculus Rift was released for a few hundred dollars, compared with the next believable headset of $50,000, and now all the big companies have gone into it .”

Slater talks softly and, facially, has a touch of Woody Allen about him. Although principally a computer scientist, he is now largely based in the psychology faculty at the University of Barcelona. Slater is one of the most-in-demand academics in the virtual world, with an endless listing of titles, including prof of virtual environments at University College London, co-founder of the company Virtual Bodyworks, and immersive fellow at Digital Catapult. He also works with Daniel Freeman on therapies for persecutory hallucinations and acrophobia.

Like Rothbaum, Slater is one of the early 1990 s innovators.” Nobody told me virtual reality died, so I stayed with it .” He smiles.

And had it died?” No, but for a long time people said,’ It’s not going anywhere because it’s too expensive .’ The equipment we used at UCL cost PS1m. The equipment I have in Barcelona, when I set up there 10 years ago, was PS100, 000. Now I can do the same thing with PS3, 000.”

Slater says the human rights reaction still astonishes him.” There is some level of the brain that doesn’t distinguish between reality and virtual reality. A typical example is, you find a cliff and you jump back and your heart starts racing. You react very fast because it’s the safe thing for the brain to do. All your autonomic system starts functioning, you get a very strong level of arousal, then you go,’ I know it’s not real ‘. But it doesn’t matter, because you still can’t step forward near that precipice .”

Virtual Simon Hattenstone explains his problems to Sigmund Freud …

Virtual … then analyses himself as Freud. Photo: Event Lab, University of Barcelona, Spain

In some styles, he says, virtual reality beats reality because it are used to experimentation in ways you can’t, physically, in real life( for example, putting people in different bodies to experience what it is like to be a different gender or ethnicity) or in situations you would avoid.

” I was in one session where the guy had such a fear of public speaking that he told us about speaking at his daughter’s wedding, and we said,’ How old is your daughter ?’ and he said,’ Three !’ So he spoke to a virtual audience. He said:’ I can’t do this, I’m turning bright red, my voice is an octave higher .’ The psychologist afterwards played it back to him and said:’ Is your face red? No. Are you speaking an octave better than normal? No .’ The psychologist did in one afternoon what would normally take 12 weeks .”

I have watched headlines is recommended that VR can cure depression. Surely that is an exaggeration?” Cure, I don’t know ,” Slater says.” But we published a study last year where we reduced the level of depression among a cohort of people through a VR intervention not that dissimilar from what I’m going to show you today. Part of having depression is that you are overly self-critical and cannot dedicate compassionate believes to yourself. So in the VR, you consider a exclaiming child. Beforehand, the therapist has given you a structure of things you should say to other people in order to give them compassion. So you say these things to the child who starts looking at you and stops crying. Then, in the next phase, you are that child, so you then find and hear your previous ego giving you the compassionate speech. When we dedicated this to a group of reasonably depressed people three times, the level of depression lessened .”

I put on my headset and sit in front of a screen. The program I’m trying, called VReflect-Me, is still being developed for people with anxiety matters and depression. It is based on the notion that, when advising friends, we are often kinder and more objective than when analysing ourselves.

First of all, an avatar is generated of me. Then I embody that avatar. I am in a therapy conference with a psychiatrist( in this case, Sigmund Freud) and I tell him my problems. In the next stage, I embody Freud. When my head moves, Freud’s head moves; when my hands move, his move; and when I’m ready, I advise myself in the form of Freud.( Slater said today Freud is a useful avatar, because you tend to adopt characteristics of your avatar; so, if he is wise, you become more wise .)

I tell Freud I have paranoid propensities; generally, I believe I’m incredibly boring with nothing to say and abhor formal social situations( not the tavern ), because I dread my folly is likely to be uncovered. More specifically, I tell Freud, I have just read comments on social media about an interview I just wrote saying that I gave my subject an easy ride. I am full of self-loathing, and feel useless at my job.

Now I switch roles, and am Freud advising me. The first time I do it, I’m too self-conscious. Slater gently suggests that I was not fully immersed. I ask if I can do it again. This time, I go for it. It might not be the style Freud would have responded, but I listen to my problems and then tear into myself- rightly or incorrectly, I make a good occurrence for not being boring, stupid and a rubbish journalist. I verbalise everything and reject it as solipsistic nonsense. I then return to my own avatar.” Good points. Well constructed ,” I say to Freud. And I mean it.

When I take off my headset and leave the virtual world, my breathing is quick and shallow- not unlike Chann’s after he’d been to the heights. I feel both ecstatic and emotional. Tearful, nearly. Even if it doesn’t last, it’s been a useful workout. I might say this kind of stuff to myself in my head, but it feels different when you say it out loud.

Slater is pleased with me.” Wow! You did amazing. You said,’ You, you, you !’ which is great .” What he entails is, I successfully got out of my head and into Freud’s. It strikes me as a powerful tool for therapists. There is no way I would have said what I said, as Freud, if I was simply talking to a real person.

But I can’t help thinking I’m a relatively safe example. What if I were more vulnerable? What, for example, if I suffered from the acrophobic’s call of the void, did the VR program, convinced myself I’d overcome my phobia, went to the nearest high-rise and jumped?

Dr Kate Anthony, an expert on the use of technology in therapy and a fellow of the British Association for Counselling& Psychotherapy, stresses that technology is there to be used alongside therapy, rather than instead of.” VR is a good opportunity for helping psychotherapists ,” she says,” but we’re not at a stage yet where virtual reality is going to be able to replicate a human therapist .”

It’s all very well, she adds, having software to encourage “youre talking” and tackle your dreads, but that will take you merely so far.” The VR therapist can’t respond in any meaningful way, and without that meaningful response, I don’t think the client is going to progress .”

Once VR treatments have been proven to be effective, she says, she would like to see them available on prescription. What about inducing them commercially available? No, she says, it’s too risky.” If we’re talking about paranoia, for example, any of these situations can trigger the customer. The trouble with something like that is it could bring up all sorts of issues. I would want to see it closely managed .”

Dr Michael Madary, a philosopher and technology ethicist, and his colleague Thomas Metzinger, have drawn up a code of conduct for the use of VR, some of which addresses its use in therapy. He supposes VR can have a positive impact, but that therapists must not blind themselves to the perils. One particularly sensitive issue, Madary says, is data. Participants in surveys know their data is confidential, but that could be very different if commercial companies invest in VR therapy purely for profit.” With motion tracking, especially facial tracking, users are going to reveal a lot about themselves- about their mental state, about how they react to various stimulus- and that data can be collected and then used as a powerful bargaining tool .”

He sees a scenario where there is an advertisement flashed, or product placed, in the virtual world and the content inventors collect the response of users to that ad based on the faces they make.” You can imagine seeing your avatar in a new coat, for example. There will be a lot of powerful techniques that emerge in marketing, with widespread employ of motion capture .”

Mel Slater is agreed that virtual reality can be abused. But anything can, he says.” You can use a bread knife to cut bread or to stab someone, so any tool can be misused deliberately. This is why I believe the applications in clinical psychology have to be led by people such as Daniel, who know the risks .”

Back in Oxford, Daniel Freeman is not so sure the programs require his presence to be effective. He is talking about his company Nowican, and anticipating the launch of its first product- Nowican Do Heights, the acrophobia program being trialled by Chann.

He said that he hoped the NHS and individual psychologists will invest in it, but believes its prime use will be for individuals seeking assistance.” We’re putting a virtual coach in there so you don’t need a therapist, and we’re also looking at better techniques than simple exposure .”

Is he in danger of doing himself out of a task?” No. We’re not saying it has to replace the therapist. Some people will want to talk to a therapist, and sometimes the complexity means you need a therapist. But the issue is, there aren’t enough therapists .” Freeman is hoping that, before long, we will be able to download this as an app on our smartphones.

In a world of diminishing NHS resources, Freeman regards it as a no-brainer:” I watch people who have been waiting 20 years and not had a chance of considering a therapist. The notion that we can give so many people the chance to access what the best therapists should be doing- that is really exciting .”

Watch the Guardian’s latest VR experience The Party, filmed from the perspective of a 16 -year-old girl with autism, on our new Guardian VR app. You can download it from the Apple App Store and the Google Play Store, or watch it as a 360 video, along with other Guardian VR experiences, at theguardian.com/ vr

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