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Imagine you’re standing close to the edge of a sixth-floor balcony. Carefully leaning out into a huge atrium, you can see lower balconies and people walking across the ground floor far below.
You pick up a bucket and throw the balls it contains into the void, watching them fall, then send the bucket after them. There’s no balcony fence to stop you walking out into thin air, so you do.
And despite knowing full well that this is happening only because you’re wearing a virtual reality (VR) headset in a ground-floor office at the University of Oxford’s department of psychiatry – as well as visual clues that the atrium is not real, such as a whale swimming through the air – you might well find it is difficult to push yourself step off the edge.
The visceral sense of height in this VR environment is deliberate; it is designed to help treat acrophobia, fear of heights. Professor of clinical psychology Daniel Freeman is working with colleagues at the University of Barcelona to build the environment, which will include a virtual instructor to guide users through game-like tasks that will challenge their fears.
Virtual instructors and other VR techniques could help patients gain access to mental healthcare, given a shortage of human therapists, says Freeman.
“VR has the potential, in essence, to let many millions of people see the best therapists for a problem. I do think this is transformative.”
He has already tested VR as way to treat persecutory delusions, by placing patients from Oxford Health NHS Foundation Trust, one of NHS England’s digital mental health exemplars, with paranoia in two virtual environments, an underground train and a lift, for a total of 30 minutes. Both were exposed to their fears of other people, but half were also encouraged to challenge them by approaching or staring at the virtual people around them.
VR and mental health
A study on the work for the British Journal of Psychiatry, reported that eight of the 15 in the latter group no longer met the formal criteria for persecutory delusions as a result. The fear of heights environment has been designed with care, with an indoor atrium chosen as most users will in reality be in a building when using it. As well as unguarded balconies it includes lifts, escalators and ledges to provide different ways of habituating users to heights.
There will be games and a scoring system, the latter shown by a flying blackboard, which currently just reads ‘Hola’. The atrium itself features floating balls and the flying whale to create a sense of depth – although Freeman says the whale was the idea of the programmers and has been left in as it is fun. The instructor, currently a blank faced robot, is likely to become more humanoid.
Freeman recently co-wrote an assessment of VR’s use in mental health over the last 20 years. It has mainly been used for exposure therapy of anxiety disorders, but the paper looks at how it could be used in other areas including substance, eating and sexual disorders, as well as for assessment of conditions.
Freeman says that VR may have less impact on generalised anxiety disorder, but wherever people’s problems are triggered by something in the environment it should be relevant. He adds that VR could also tackle common fears such as public speaking.
The reason this hasn’t yet happened is simple. “It’s expensive, and you need good expertise,” he says. “The fear of height environment will take a team of around five people nine months to complete.
However, the advent of VR headsets costing a few hundred pounds means there may be a way to justify such development work. After clinical trials Oxford VR, a spin-off company owned by the university and co-founders including Freeman, hopes to make the height environment available commercially.
Dr Stéphane Bouchard, a professor at Université du Québec en Outaouais’ department of psychology, is similarly working to develop VR environments for mental health conditions including social anxiety disorder, whose sufferers fear social interaction. A paper he co-authored for the British Journal of Psychiatry compared a VR-based treatment to standard exposure therapies and found it to be as effective and on some measures superior – as well as cheaper. The gains experienced by patients were maintained after six months, the research found.
Bouchard says the virtual environments used for treating anxiety are generally video game-like rather than highly realistic. This is partly because they use less computing power but also because they leave room for the user’s imagination. “Highly realistic environments don’t matter for anxiety,” he says. “People are dealing with emotions that are triggered too easily by things they are afraid of,” such as arachnophobes whose fears can be set off by unconvincing fake spiders.
Bouchard sees potential in using artificial intelligence with VR, such as to train mental health practitioners with virtual patients in high-risk situations such as terrorism. Like Freeman, he is involved in a spin-off company, In Virtuo, which has made sales in Norway, France and Belgium.
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The University of Melbourne is working on using VR to train patients themselves, specifically to help teach young people to use mindfulness techniques, which while often effective require effort to learn. “Existing methods of teaching mindfulness techniques rely on abstract concepts and can be difficult for young people to understand, remember, and master,” says Greg Wadley, a lecturer in the university’s school of computing and information systems.
“Young people, especially those with mental health issues, can become bored or frustrated when a counsellor attempts to explain these complex concepts. VR, on the other hand, might be able to visualise these concepts in a clear and memorable way.”
With Orygen, a youth mental health clinic, Wadley and colleagues are building their own apps for HTC Vive headsets, to be used at clinics under clinicians’ guidance. He says that participants enjoy using commercial VR software such as Google’s Tilt Brush: “We want the ‘wow factor’ of VR to boost young people’s enthusiasm for taking part in psychotherapy,” he says.
Wadley says they have learnt that it takes a lot refining to get details right in a VR environment. “Should the scene be realistic or abstract? What is the minimum level of detail and interactivity required to make an app interesting? Conversely, is it possible for a well-designed VR experience to distract users from its therapeutic purpose?” They are using iterative, user-centric design to improve their apps based on how users react.
Some organisations are using VR to help patients with fears that can affect other kinds of healthcare. Over the last two years, Nationwide Children’s Hospital in Columbus in Ohio has developed Voxel Bay, a game designed to help young patients with haemophilia cope with needle phobia. Given their need for regular injections, this can seriously affect their care.
Jeremy Patterson, lead of user-experience technology research and development, says the hospital considered several ideas to help such patients – as well as families and professionals, who are affected by a child’s distress – and that VR emerged as the best option.
“Being able to put someone in a different reality with games and activities was going to be the ultimate form of distraction,” he says. The hospital has undertaken a clinical trial on the game and although the study has not been published yet, “the data that we collected looks very, very promising”.
Voxel Bay is a seafaring adventure where players sail to different locations and play simple mini-games such as searching for different creatures during an underwater swim. “We set out to design a seafaring adventure where the player would use their head movements and breathing to capture tree spirits, escape from pirates, launch crabs at seagulls, and many other fun activities as they sail from island to island during their procedure,” says John Luna, a graduate intern at the hospital who researches gaming at Ohio State University’s advance computing centre for the arts and design.
Minecraft meets Lego
The VR game, which like many others uses Unity’s development platform, employs graphics described by Patterson as “Minecraft meets Lego,” which allows it to work well on basic hardware. Water is often used in making clinics more relaxing, hence the choice of location.
Given the aim of minimising VR sickness, the mini-games are designed to work with minimal movement. Luna says that one involves guiding a character through a maze to claim pirate treasure: “When the player looks to the left side of the virtual screen the character would follow and run to the left,” he says. “This encourages the player to keep their head forward and focus their attention to a narrow cone of space in front of their head.”
Several of the mini-games including the underwater swim feature a virtual headset which creates a tunnelling effect, helping to minimise such sickness as well as linking to the fact that the patients actually are wearing a headset.
Patterson says that the game does not work with all patients – some do not want anything covering their face, although they have the option of an in-game window showing them what is happening in the real world. But for some of those who do use it, “the transformation of behaviour has been nothing short of remarkable,” he adds. The hospital is exploring ways to make Voxel Bay available commercially, as well as considering a group version and its use in other settings, including primary care.
VR as a pain reliever
Doctors are using virtual reality to control other types of pain. Pain Consultants of East Tennessee uses Cool, an environment designed by VR specialist Firsthand, to provide an alternative to opioid drugs – which can be highly addictive – for chronic pain sufferers. The software was recently demonstrated to audiences at the National Theatre production of Ugly Lies the Bone, a play which looks at how VR is used in treating soldiers experiencing post-traumatic stress disorder – one the earliest ways in which the technology was used in healthcare.
Dr Ted Jones, a clinical psychologist at Pain Consultants, says VR provides very good pain relief to about 95% of patients, although the effect usually wears off soon after the patient removes the headset. However, “it works well and it’s easy – all you’ve got to do is put something on your head and play with penguins”.
Dr James Choo, Pain Consultants’ medical director, adds that VR provides a useful alternative to drugs for short-lasting pain relating to flare-ups: “It’s an extra tool in the toolbox,” he says. It can also be useful for specific medical procedures where drugs are already being used and a further one could lead to over-medication. There is also potential for VR to be used in other areas, such as to train injured patients in how to move.
But Jones says there is a shortage of programmers with specialist knowledge: “Developers are generally not aware of healthcare issues,” he says. “We somehow need to link the healthcare world to the developer world.” There are specific problems in US healthcare in that most insurers do not cover VR treatment.
Aside from mental health and pain management, VR can also help prepare both patients and practitioners for procedures. King’s College Hospital NHS Foundation Trust has created an app for children about to undergo their first MRI scan, which when used with a headset allows them to preview the whole experience through VR from arriving at reception to the scan, noises included.
Meanwhile, Alder Hey Children’s NHS Foundation Trust has used VR to help surgeons better understand the results of MRI scans, by using them to build a virtual model of a child’s heart. This helped surgeons plan a successful operation carried out in August 2016, after the trust’s clinical innovation director Iain Hennessey saw a presentation on VR work involving Bentley Motors and University of Liverpool’s virtual engineering centre.
“What they really liked was being able to resize the heart,” says the centre’s commercial director Lynn Dwyer, along with the ability to see inside it. “From the surgeon’s point of view, it helped their understanding.” The university has a small innovation centre at Alder Hey, and there has been interest from other surgeons. Dwyer says the technique could also be used for training and teaching.