Using virtual reality to overcome anxious social avoidance

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irtual reality (VR) has become increasingly prevalent across the healthcare market and is now used for a wide range of indications, from helping pregnant patients manage the pain of labour to immersive surgical training. But one area in which it could prove particularly advantageous is the treatment of mental health conditions, something one in four UK residents reportedly experience each year.

Cognitive behavioural therapy (CBT) is one of the most popular and well-researched talking therapies for mental health conditions. It focuses on challenging and changing unhelpful thoughts, beliefs and attitudes by developing coping strategies that can improve a patient’s related emotional regulation and behaviour. Through CBT, an anxious or phobic thought can be translated into a neutral or even positive one.

A key component of CBT is situation exposure, where patients are gradually exposed to situations that cause them distress until they lead to fewer negative feelings. A person who feels anxious about social situations may visit a busy supermarket with their therapist, where they can work on accepting the belief that bad things won’t necessarily happen to them whenever they enter a public space.

Anxious social avoidance is one of the mental health complaints targeted by Oxford VR (OVR), a spinout from the University of Oxford, through its ‘OVR social engagement’ platform. The company takes situation exposure and translates it into a virtual environment, where the patient is guided through an automated situation by a virtual coach, completing a series of graded tasks in different everyday environments, such as riding a bus or going to a shop.

By carrying out these virtual tasks, users can develop strategies to cope with their anxiety triggers when they experience them in the real world.

OVR chief operating officer Arvind Tewari says: “What makes VR so special is the immersive nature of the therapy – you’re given a multisensorial experience, which enhances the therapy and allows you to really elicit emotional and physiological responses identical to the responses you develop in a real-life situation. The idea it is it will deliver superior results relative to speaking therapy, because it’s incredibly engaging.”

Anxious social avoidance needs to be managed in different ways depending on the condition from which it arises. Somebody with generalised anxiety disorder, who might feel maladaptively nervous about going to a party, will need very different treatment to someone with psychosis, who feels scared to go into a public space in case they become overwhelmed and experience a delusion.

OVR social engagement is geared up to treat anxious social avoidance in people with psychosis, who experience it as a symptom of schizophrenia, bipolar or major depression disorder. OVR then has a separate product that is derived from OVR social engagement but is ultimately targeted towards severe social anxiety in people that don’t experience psychosis.

“The non-clinician eye will interpret some overlap between the psychosis product that we’ve got and the social anxiety product that we’ve got, but clinically they’re very different,” says Tewari. “People suffering from psychosis are crippled with fear about going into social situations because they are very worried that they will see more hallucinations, think through more delusions and they’re also terrified about how people will react to them reacting to their own hallucinations.”

Of course, there’s a case to be made that VR therapy simply cannot be as effective as real-life situation exposure – no matter how fine-tuned it is – because the patient will always know that the situation they’re in isn’t real. But for people with severe anxious social avoidance, carrying out situation exposure exercises in VR can be a crucial first step.

Tewari says: “For individuals with psychosis, taking them into social situations to walk them through CBT therapy can be impossible, impractical or totally unsafe. But VR creates the same physiological and psychological responses as being in a real-world scenario.

“People do know it’s not real, but your instinct reacts quicker than the logical parts of your brain. If you have a fear of heights and we simulate that environment in VR, you get stressed before your brain can logically say ‘hang on, this is just a VR headset, this isn’t real’. It’s also important for some people to know that it’s not real – if they didn’t know there was a degree of fantasy then they just wouldn’t do it, it would be too scary for them.”

Tewari says that delivering mental health care through VR allows the firm to solve a number of drawbacks associated with traditional CBT, one of which is simply accessing the treatment.

Many patients find that there simply aren’t enough mental health professionals available to treat them, particularly in the US where OVR is currently looking to expand. While OVR’s platform could be used alongside standard CBT with a human therapist, it’s designed to function as a standalone product too.

“The alarming fact I always say is that 50% of counties in the US don’t have a single psychologist or psychiatrist, which is astounding when you think of how many people in the US will suffer from a mental health disorder each year,” says Tewari.

Providing a way to access CBT without necessarily having to work with a therapist could prove to be a lifeline for patients who are unable to access traditional care pathways.

VR therapy does come with its own, fairly obvious, barrier, in that patients will need to purchase a VR headset. But a course of CBT can often wind-up costing even more than a VR headset in the long run, meaning OVR’s platform actually may be a better investment for some patients.

Delivering CBT via VR also helps to standardise the treatment across patient pools. While interpersonal nuances mean that individual therapists will deliver a different quality of experience for each patient, OVR leaves every patient speaking to the same virtual coach. This gives the company a baseline of quality on which the condition of a patient can be assessed.

In fact, OVR is also looking to personalise its therapies further by collecting data on patient’s reactions while they’re working with the VR platform. It is currently working on a functionality that will allow it to measure data about platform users’ heart and breathing rate through a wearable, in order to provide a qualitative measurement of the VR’s efficacy.

While the progress of a patient undergoing talking therapy is typically assessed through a patient health questionnaire, being able to measure physiological parameters could give OVR a more objective assessment of how their product is performing.

OVR social engagement is currently being run through a randomised control trial as part of the UK NHS’ gameChange project. Meanwhile OVR’s non-psychosis social anxiety product is being trialled in Hong Kong. The company also has a third product in the works, again based in the principles of CBT, this time to treat anxiety and depression.

“We’re very much in the trial phrase of testing our product,” says Tewari. “We have a couple of partners in the NHS that are already using it as part of their usual treatment pathways. Once the Hong Kong trial is done, we’ll make that available in Hong Kong, and we’re stepping up some partners in the US as well.”

Of course, OVR – and other platforms like it – are unlikely to eliminate the need for human therapists anytime soon. But as they become more prevalent, they could help to expand the way we think of therapies like CBT, providing a flexible and interactive way for patients to receive mental health support.