Virtual Reality May Soon Become Clinical Reality in Psychosis Care

The concept of using computer programs to prepare for interviews is not new; programs like Molly training have been used as training modules since the 1990s, though their initial design was to help professionals improve communication in instances such as interrogating a witness or conducting a behavioral therapy session. More recently, researchers have seen the potential for VR programs to help patients as well.

Clinical studies are currently evaluating the ability of VR-based programs to help servicemembers and veterans with posttraumatic stress disorder engage in dialogue about their symptoms, improve communication in people who have had a stroke or traumatic brain injury, and bolster social skills in people with autism.

Pilot work done by Smith and his colleagues has shown that people with psychosis who completed about 10 hours of Molly training sessions had about twice the odds of receiving a job offer after six months compared with patients who did not receive Molly training. The people who used the program also reported that it was helpful and easy to use.

Smith acknowledged that while participants in his study were all in a position in their lives to start job seeking, he thinks similar VR coaching programs could be used earlier in the recovery process as well. “[VR] could be a starting point to get patients engaged in recovery and help them boost fundamental skills like empathy or theory of mind,” he said. (“Theory of mind” refers to the intrinsic understanding that other people possess their own values and beliefs.)

The major concern about using VR earlier in psychosis recovery—where it would be more a therapeutic tool than a skill training tool—is that VR applications might be harmful to people whose symptoms typically include feeling detached from reality, said Lucia Valmaggia, Ph.D., a clinical psychologist and head of the Virtual Reality Lab at King’s College London. “But we conducted some studies using immersive environments and found that when done properly, VR does not increase any feeling of detachment or create other distress. [Patients] understand what is real versus virtual.”

This past March, researchers in the Netherlands published one of the first clinical trials showing that VR-assisted behavioral therapy is not only feasible, but it can help reduce paranoid thoughts and anxiety in patients with psychosis. The VR sessions involved placing the patient in a virtual environment to encourage interaction and eye contact with digital avatars.

“The beauty of VR is that it combines both ecological validity and experimental validity,” said Valmaggia, who in addition to her psychosis research is also exploring VR to help people with eating disorders improve their body image. “You can control the settings to have a well-regulated environment so nothing unexpected occurs, as opposed to taking a person out to a pub to interact.

“Now, every psychiatric therapy has the risk of making the patient’s condition worse, and VR, as an emotionally evocative technology, is no exception,” Rizzo continued. “We have to be careful, so our treatment efforts do not go in the other direction.”

Smith agreed. “There is a lot of excitement in technology-based mental health care, but we have to do our due diligence,” Smith said. “We are taking the approach that interventions aren’t ready for the public until they can be considered an evidence-based tool.”

Developing an evidence base is critical, but Valmaggia wonders how feasible it can be given how quickly VR technology is changing. The gold standard for medications—long-term randomized clinical studies, which can take years from concept to completion—may not be appropriate, since the technology will have moved on, she said.

“It’s a moving target to be sure,” Rizzo said when describing what the goals of psychiatric VR might be. “Remember, this is still a young discipline. … [T]here is still much we don’t know about how people behave in the real world. Now we have to figure out human behavior in virtual worlds.” ■