As defined by the Mayo Clinic, agoraphobia is “a type of anxiety disorder in which you fear and avoid places or situations that might cause you to panic and make you feel trapped, helpless or embarrassed.” This can range from using public transportation to standing in line in a grocery store. Most people diagnosed with agoraphobia fear public spaces and crowds, thus they confine themselves to their home in order to avoid having a panic attack. Treatment involves psychotherapy and medication, but it takes time for symptoms to improve. Cognitive behavioral therapy is the most widely used treatment because it gradually exposes patients to anxiety-inducing situations, teaching them how to manage their symptoms and overcome their fears. 

A recent study out of England analyzed the effectiveness of virtual reality therapy to treat agoraphobic avoidance and patients with psychosis. Researchers analyzed 346 patients who were clinically diagnosed with psychosis and “had self-reported difficulties going outside due to anxiety.” Over the course of 26 weeks, researchers conducted “a parallel-group, single-blind, randomized, controlled trial across nine National Health Service trusts in England.” They split patients into two groups – a VR therapy group and the usual care alone group (control). The VR group was immersed in several different environments over the course of treatment. Whether it be visiting a coffee shop or entering a waiting room, patients were coached the entire way through and encouraged to let go of defensive behaviors. Compared to the usual care alone group, the VR therapy group showed “significant reductions in agoraphobic avoidance and distress” in everyday situations. VR therapy “particularly benefited patients with severe agoraphobic avoidance, such as not being able to leave the home unaccompanied.” 

The results of this study indicate VR therapy as a powerful adjunct to cognitive behavioral therapy. This means that, with the use of immersive technologies such as VR, therapy will become much more widely accessible and affordable to patients, especially those who may be too anxious to leave their homes for treatment. Foretell Reality is a social VR platform that provides safe spaces for therapy and support, soft skills development, and other interpersonal activities like real time collaboration and group events. Please visit our website for more information or to schedule a demo.

If you live in the U.S. where the combined rate of anxiety and depressive disorders among adults is approximately one in three, you likely know someone who suffers from the disorders’ crippling symptoms such as hopelessness and guilt. Perhaps you yourself have experienced a depressive episode and were encouraged to seek help, but for a multitude of reasons that we will touch on later, you didn’t. Virtual Reality (VR) reduces the barrier to engagement in mental health treatment and recent research shows that it can be used as a powerful tool against anxiety and depression.

The focus on anxiety and depression is relatively recent, but the relationship between VR and mental health is decades old. The first mental health breakthrough occurred in the 1990s when VR exposure therapy was used to treat war veterans with Post-Traumatic Stress Disorder (PTSD). VR exposure therapy simulates life-like stimuli in a controlled environment. Under the supervision of a mental health professional, patients confront the object or scenario they fear, thereby diminishing their anxiety over time. VR exposure therapy treatments were also developed for phobias such as claustrophobia, arachnophobia, and fear of flying. Additionally, early VR therapies focused on cue reactivity for addictions like nicotine. Because VR makes the scenario feel real, patients are able to practice their behavior when confronted with stimuli (e.g. a crowd of people smoking) that trigger their arousal and anticipation.

Early VR treatments like exposure therapy and cue reactivity were one-on-one. And often the therapist was not immersed in the space with the patient, but rather was guiding the session from the outside. More recent technological developments have enabled multiple participants to interact in a shared environment, which has made VR  support groups and group therapy a reality. 

In one example, Yale School of Medicine partnered with Foretell Reality to study the viability of VR support groups for adolescent cancer patients. VR allows something that other types of therapy (e.g. tele-health via video) do not – anonymity. If you’ve experienced depression or know someone who has, you’ll be familiar with the heavy burden of social interaction. If you’re losing your hair due to cancer treatments or your depression has taken a toll on your hygiene habits, you can understand why some would avoid group therapies altogether. Because VR is avatar-based, patients do not feel judged as they are not physically “seen.” At the same time, they can still interact with other avatar patients through body movement and gestures as if they are in the same physical space. 

Anonymity helps solve the burden of stigmatization regarding physical appearance, but that isn’t the only barrier that VR addresses. Those suffering from depression and anxiety may experience challenges focusing. With a VR headset on, it isn’t possible to look at your phone or be distracted by the television. A patient is fully immersed in a virtual supportive environment: chairs in a circle, the cushy pillows… everything looks… real. And the possibilities are endless. Perhaps your support group is meeting by the ocean or on a serene clifftop nestled in the clouds. You are there – and you didn’t even have to leave your home. You can use different settings for a daily meditation or mindfulness practice, walk on the beach with your guide while discussing your feelings, or play a virtual ball game with your peers. 

And that brings us to another barrier to mental health treatment: the physical one. Some patients are disabled and literally cannot leave their homes. Others live in a rural area with no accessible support group within hundreds of miles. And depressed patients may at times not feel physically capable of leaving even their beds. A $300 headset and internet connection is all one needs to connect socially from anywhere in the world. 

VR technology has been evolving for over two decades, and has greatly accelerated in the past couple of years. This evolution comes just in time for using VR effectively for various (tele) mental health purposes. In less than ten years, the World Health Organization predicts that mental health disorders will be the leading burden of disease worldwide. We must use every available tool to treat mental health disorders, and VR is here to help.

In person group-based intensive outpatient programs (IOPs) have shown promising results for adults with serious mental illnesses. At the start of pandemic, these IOPs were forced to meet remotely through video-based telemental health (TMH) platforms presenting an opportunity to better understand the benefits and drawbacks of online group therapy.

A recent study from the Mayo Clinic focused on TMH group-based IOPs, providing insight into the effectiveness of and overall patient satisfaction with this type of treatment. Researchers interviewed 76 patients with diagnosed serious mental illness (SMI) who participated in an online video group based IOP.

Researchers gathered their data using a 17-item questionnaire covering 3 areas: “IOP TMH satisfaction, future recommendations, and video technology challenges.” According to the feedback they received, “the majority of patients reported high satisfaction, comfort, appropriateness, relevance, and compatibility” of the TMH service, 92.5% of them reporting “that they would recommend this service format to a friend or family member.” Most patients were glad to have the option for treatment during COVID, one even commenting that it was “just like being in a room full of people” and it “saved [their] life.” 

Despite the fact that group telehealth was viewed favorably overall, there were reported challenges during the program. Slow internet connection, poor video camera quality, login problems, and accidental removal from the session were the most highly reported of these challenges. One of the participants noted that the Zoom meetings didn’t feel as welcoming, and “’there couldn’t really be a discussion [as if they were] sitting in the same room.’” Another wanted “more collaboration among the patients.”

Other participants wished they had used “’more of the Zoom features such as the whiteboard,’” or recommended “’some tabs to find things [easier].”’ There seemed to be a large disconnect with the learning materials in general. Patients suggested that administrators work on “improving the structure of the binder.” Some of the patients didn’t like the program at all because of the video format and desired something more immersive and interactive.  

Though the study affirms that remote group therapy was well received in general, there were clear deficiencies noted. Virtual Reality (VR) for group therapy addresses many of these concerns and offers other benefits not possible through video-based TMH.

“poor video camera quality”

Instead of sitting in front of a camera, group therapy in VR allows participants to sit, lie down, or walk around in their physical environment. More importantly, everyone is portrayed as a personalized avatar which creates a consistent visual and auditory experience regardless of room lighting or camera or microphone quality. The need not to be on camera also takes away judgement of physical appearance and removes outside environmental distractions.

“there couldn’t really be a discussion [as if they were] sitting in the same room”

Unlike group video sessions in which everyone is arranged on a flat grid, VR sessions are held in a shared, 3D environment. This means that participants who look around the room will see one another from the same perspective as they would in the physical world. For example, to see the person who is slightly out of view to my left, I would turn my head in that direction and they would appear in front of me. Since everyone is sitting in a shared environment, they also see the same things as one another creating a stronger sense of connection.

“more of the Zoom features such as the whiteboard”

Just as with Zoom, VR offers many tools for collaboration and instruction including white boards, sticky notes, and media presenting. But VR also provides the ability to manipulate and pass 3D objects, draw in space, and watch fully enveloping 360 video.

“more collaboration among the patients” 

True collaboration in Zoom in a challenge because we as humans collaborate in 3D space. VR provides the ability to collaborate in ways not possible on Zoom whether that means team building exercises, collaborative role play with avatars, or simple games that bring people together.

“improving the structure of the binder”

A foundation of many IOPs is the presentation of a structured curriculum which is outlined in binders provided to patients who follow along during each session. With limited space to view and absorb material, video sessions present a challenge when it comes to conveying this material. With VR, patients can reference their binder from their own personal screen while also collectively viewing material on the therapists screen(s). Navigating between materials and interacting with them is much more intuitive as it mimics the 3D world.

VR also provides benefits not identified above. For example, avatars allow for exploration of identity, role play activities and anonymity if desired. All or parts of sessions can be recorded and played back in 3D allowing for analysis and reflection from the group. And analytics such as time spent speaking and direction of gaze provide insights for both patient and therapist.

Foretell Reality is an avatar-based, multi-participant virtual reality platform specifically designed for group therapy and support. Please click here for more information or to schedule a demo.

Tele-health options are on the rise in recent years, and have especially flourished during the COVID-19 pandemic. Mental health therapy has evolved from largely in person-only to including other methods like web-based applications (e.g. Zoom) and Virtual Reality (VR) that make health care accessible in the comfort of one’s home without the constraints of transportation and other logistical barriers. Researchers are beginning to study the dynamics of virtual communication and how this medium compares with face-to-face conversation. Findings can be especially relevant for mental health therapists who seek to provide the ideal environment for patient comfort to disclose thoughts and feelings, thereby facilitating more effective therapy. 

At Edith Cowan University in Australia, researchers studied social interaction in two contexts – one in which participant and researcher engaged in casual conversation, and the other in which the participant was instructed to disclose both positive and negative personal experiences to their research conversational partner. These contexts were studied within a face-to-face condition as well as a virtual condition, wherein the researcher was represented via avatar in real time through face and body motion capture.

While participants had an overall slight preference for face-to-face interaction, one of the findings is of particular relevance to mental health practitioners. In the disclosure of negative information context a significant portion of the participants (30%) preferred the interaction with the avatar over the in-person conversation, specifically on the facets of self-disclosure, comfort, and being able to relax and be oneself. The researchers suggest, “the increased sense of interpersonal distance in VR may be why some of our participants indicated such preferences for VR over face-to-face for negative disclosure”. Furthermore, they surmise that a study conducted specifically with a socially anxious participant population could yield an even greater preference for virtual reality when disclosing negative experiences.

It also makes sense to consider that participant comfort level with the avatar could be higher in conditions that more closely align with communication norms. In the present experiment, the virtual partner, represented through an avatar, was standing while the participant was sitting.  This dynamic of the participant sitting while the avatar stood had the potential to lessen participants’ level of comfort and ability to relax, as it may have felt more unnatural. Ideal study conditions would have mimicked the typical conversational interaction of two people sitting and speaking (as was the case in the face-to-face interaction), but researchers had the avatar standing behind a desk in the VR condition to avoid a potentially distracting technological effect of the avatar “clipping” with the table. Clipping is a technical glitch that can be easily avoided with a careful design of the VR environment.

Also, in this study, only the research conversational partner was represented via avatar while participants were not. Participants were aware that they were not anonymous as their conversation partner could see them sitting with a VR headset on. Further studies that allow participant anonymity that shields identity through an avatar could be useful to mental health practitioners. For many suffering with anxiety and depression, their physical appearance (for example, due to hair loss associated with chemotherapy or body image issues) can be a deterrence to participating in group therapy. It may be possible that the avatar anonymity in VR could increase their willingness even more to disclose information and participate in group discussion.

Foretell Reality is a VR platform that provides safe, secure environments, customizable avatars, and moderation tools for clinicians to facilitate individual and group therapy sessions, support groups, and other behavioral health treatments.

Speaking with a therapist or social worker over video has become much more commonplace over the past two years for obvious reasons. The experience, though not perfect, provides for ‘face-to-face’ communication, albeit in two-dimensional space, and it addresses the need for remote treatment which is critical.

The same cannot be said when it comes to group therapy and support. The Brady Bunch style grid of faces on a flat screen simply does not work well when it comes to facilitating open and natural group conversation.

Virtual Reality offers an alternative to video, one that realistically mimics a group setting and the dynamics of group interactions in three dimensions rather than two. Not only that, features such as personalized avatars, shared customizable environments, and moderator controls provide certain benefits not possible online and even with in-person groups.

Below are examples of five groups where VR offers specific benefits over video.

Rare Diseases

People with the same rare diseases and their families face many unique challenges including physical limitations, lack of information, and the ongoing emotional toll of living with uncertainty. Support groups in VR offer an alternative to having to be on camera whatever condition you may be in. Everyone in the group appears as a playful though expressive avatar adding levity to difficult conversations. And VR is an amazing tool for sharing information whether it is videos, websites, or even 3D models and 360 videos related to a particular condition.

Recovery

Anonymity is critical to many people seeking recovery, particularly for those who may be well known in their profession or community. This dissuades many people from seeking the support of others. VR allows complete anonymity through an avatar and voice masking while also providing the feeling of shared presence that is core to the support group experience.

Dialectical Behavioral Therapy (DBT)

Group sessions are one of the main activities in DBT therapy. Each session follows curriculum developed by clinicians and lead by trained therapists. Sessions can cover concepts like distress tolerance, acceptance, and mindful awareness and involve sharing of videos and other materials as well as role play. VR is a very powerful tool for mindfulness exercises and it has often been called the ’empathy machine’ for its ability to change ingrained attitudes and behavior.

LGBTQ+

We wrote a recent blog post about the challenges and opportunities social VR presents for the LGBTQ+ community. Safe, secure support groups lead by either a peer, social worker, or clinician offer an alternative to those who want to remain anonymous but also still feel viscerally connected to others. Avatars also offer a unique opportunity to explore identity and empowerment without the constraints and limitations of real world appearances.

Autism

Autism is a spectrum disorder meaning it affects everyone differently. Adults and children with autism may have varying levels of challenge with behavior, social skills, verbal and non-verbal communication, and sensory and attention issues. A tailored group experience in VR lead by a trained therapist offers a focused and controlled experience not possible online. Spaces specifically designed to feel calming and comfortable can also allow for practicing social skills and interpersonal communication through avatar role play. Similarly, the anonymity afforded by an avatar facilitates open conversation and provides an avenue to explore facial expressions and gestures.

Foretell Reality is a social VR platform that provides safe spaces for therapy and support, soft skills development, and other interpersonal activities like real time collaboration and group events. Please visit our website for more information or to schedule a demo.