How virtual reality therapy is shaping mental health

VR can be defined as a “computer-generated three-dimensional (3D) simulation, such as a set of images and sounds of real-life situations, with which one can interact in a seemingly realistic way by using special electronic equipment.”¹ With simply an off-the-shelf VR headset (developed for use in video games) and software that creates a virtual environment, psychologists can use VR to assess or treat patients.

For mental health assessment, says Lucia Valmaggia, professor of clinical psychology at the Orygen Digital XR Innovation Lab at the University of Melbourne, “you might want to see how somebody feels or behaves in a certain situation.” As an example, she mentions creating a scenario in which a patient shops for groceries. The therapist can see in real time which triggers disturb a patient; this can help in prescribing appropriate treatment.

In assessment or treatment, “virtual reality is a really good enhancement tool, but it’s not a replacement,” for the therapist, says Kim Bullock, founder and director of Stanford’s Neurobehavioral Clinic and Virtual Reality & Immersive Technology Clinic and laboratory. VR “is used interactively with a therapist as a patient’s guide and coach.” However, VR therapists are being rolled out in some situations.

The virtual experience

As a scene unfolds in VR, the image does not always look real, which leaves a patient in no doubt that the images are generated by a computer. Surprisingly, that does not matter. “When there’s emotion or fear involved, your brain doesn’t require a completely realistic setting for something to be, for example, frightening,” Bullock explains. In some cases, it helps a patient to know that the simulation is not real, says Freeman. “The beauty is that the conscious awareness of these simulations allows people to try things that they would be wary of in real life, but the learning leads to major benefits in day-to-day life,” he says. VR works because it “gets to the heart of successful treatment: helping people make direct learning of better ways to think, feel, and behave,” says Freeman.

As in any healthcare treatment, however, the details matter. “VR is extremely powerful when the content is right, but get the content wrong and it will be ineffective and underwhelming,” Freeman says. “To separate the wheat from the chaff, it is crucial that each VR treatment is tested in a rigorous clinical trial.”

As one example, Freeman and his colleagues are running the Phoenix VR self-confidence therapy trial². This clinical trial was designed to help young people with non-affective psychosis increase their psychological wellbeing and self-esteem by improving positive self-beliefs. “Phoenix provides direct experiences of achievement, coping, enjoyment and relaxation that are used to spark such activities in the real world,” says Freeman. Participants used Phoenix at home and were offered weekly meetings with a psychologist. VR scenarios included tending a virtual community garden, speaking to a camera in a virtual TV studio, or playing games at the edge of a forest, near a lake. Participants reported an increase in positive self-beliefs after the small, 6-week trial³, with recruitment for a larger trial now underway.

Virtual therapists

In some ways, applying VR to mental health is easy, as a therapist can purchase a VR headset, such as the Meta Quest 2, for less than €250. However, developing virtual scenarios is much more difficult and usually requires hiring a programmer to create the needed software. “There [are] very few systems that are really set up for therapists,” says Bullock. “What we’re using is very limited as far as content, and that’s one of the barriers right now.” For example, if a therapist wants to create a specific scenario, it will usually need to be custom programmed.

Uptake of VR has been low, with few psychologists trying the technology. For example, in Bullock’s department of approximately 500 clinicians, only about 5 of them use VR to treat patients. Lack of training in VR hinders wider adoption by psychologists, she says.

VR can help with one of the biggest challenges facing mental health care: a lack of therapists. In the United States alone, 122 million Americans (more than one third of the country’s population) live in areas that lack sufficient mental health resources to meet demand, according to the US Health Resources and Services Administration⁴. Similar shortages exist around the world. As Freeman says, “There are too few skilled therapists delivering the best treatments to meet the high demand, meaning that millions of people are left waiting for the right help.” He believes that VR can solve that shortage.

“Standalone VR treatment does not need a therapist,” says Freeman, as shown by the rollout of gameChange, a VR-based cognitive therapy that has been approved for use in the UK’s National Health Service⁵. The VR tool, which is marketed as a CE-marked class 1 active medical device, allows participants to experience six scenarios: a café, a general practice waiting room, a pub, a bus, a street, or a small local shop. “A virtual therapist voiced by a real person guides the patient, helping them practice techniques to overcome difficulties,” Freeman says.

GameChange is a VR-based cognitive therapy approved for use in the UK’s National Health Service.

The therapy, which uses a virtual coach, is designed to help patients with psychosis re-engage with outdoor activities, such as cleaning graffiti from a wall.

Freeman and his colleagues tested the safety and efficacy of gameChange on people with psychosis who also experienced agoraphobia, and therefore avoided leaving their homes⁶. Freeman’s randomized controlled trial showed that gameChange led to reductions in distress, allowing some participants to leave their home unaccompanied. This tool helps “patients re-engage with day-to-day activities, taking them from a housebound existence to life back in the world outside,” Freeman says.

Automated approaches to VR-based treatments of mental health could also benefit from incorporating artificial intelligence (AI). That is just what psychiatrist Omer Liran, co-director of the virtual medicine program at Cedars-Sinai Medical Center in Los Angeles, and his colleagues did with XAIA (extended reality artificially intelligent ally) — a digital therapist. “The idea was not to replace mental health professionals,” explains Liran, “but to augment their work and give access to people who otherwise don’t have access.”

At first, Liran held little hope that XAIA would work, but as the AI-based software trained for months on transcripts from patient–therapist sessions, he says, “it went from terrible to really suddenly getting better.” Patients, Liran says, “loved interacting with XAIA, and many told us that they sometimes prefer it to their own psychologists.” Soon, Liran and his colleagues plan to start an effectiveness trial of XAIA.

However, Freeman warns that VR is only part of the solution to mental health challenges around the world. “VR can only be one part of mental health care, and not the whole system,” he says.

Opportunities in space

VR has proven useful in one of the most mentally challenging situations that humans ever endure: flying into space. Astronauts “have extremely stressful days and live in an extremely dangerous environment,” says Per Lundahl Thomsen, chief technical officer of Denmark-based Nord Space, who is working to ease that stress with VR.

VR is a useful tool to ease stress during space travel, for exercise and for improved mental health.

In this video, astronaut Andreas Morgensen uses VR aboard the International Space Station.

However, Thomson had a major challenge: VR headsets do not work in microgravity, as gravity is used as a reference for the accelerometers inside the headset, to track a person’s movement. Thomson collaborated with HTC VIVE in Taiwan to produce the VIVE Focus 3 VR system. Instead of interpreting movements relative to gravity, this VR headset compares head movements to the position of a controller, which serves as the reference point.

Astronauts aboard the International Space Station can choose from a selection of stress-easing VR simulations, including swimming with dolphins.

At the time of this writing, Danish astronaut Andreas Mogensen had tested this device 15 times during his time as the commander of the International Space Station. Mogensen’s VR setup includes five 360-degree, high-resolution movies that he can watch, including virtually walking along a beach or even swimming with dolphins. Although the clinical efficacy of this approach remains to be confirmed, just as with many other VR applications, Thomsen says that Mogensen is “enjoying this very much right now.”

Adding augmentation

If VR is a complete submersion in a virtual world, augmented reality (AR) is technology that adds virtual elements to the real world. For example, a patient who fears riding the subway could have a real train ride enhanced with virtual passengers, visualized through the use of a headset or smart glasses.

Tuba Mutluer, an assistant professor and child and adolescent psychiatrist at the Koç University School of Medicine in Istanbul, Turkey, and her colleagues recently reviewed the mental health potential of AR⁷, and concluded that interacting with virtual characters appeals particularly to children. AR “helps to enhance their emotional processing and social communication,” Mutluer says. It can be especially useful for children with autism, she adds, who “are exposed to social interactions with virtual characters and learn essential social cues and emotional recognition.”

AR adds virtual elements to the real world, which can help children with autism improve their social communication skills. 

The video shows Ida, a character in AR, which can be used alongside a school textbook.

Beyond mental health, Mutluer is interested in using AR with children who are being treated for cancer or chronic diseases. Children undergoing treatment for cancer face many mental health risks; they are 29% more likely to face anxiety, 57% more likely to suffer from depression and 56% more likely to develop psychotic disorders compared to healthy siblings and control participants without cancer, according to a meta-analysis⁸.

Those mental health risks could potentially be reduced with AR-based therapies, although the approach is completely untested — for now, says Mutluer. Using an AR character named Ida, Mutluer helps children deal with the emotions connected to being diagnosed with and treated for cancer. Although this work is unpublished, testing Ida with 12 children with cancer “revealed that children enjoyed the AR aspect of the animation and were interested in it, finding it fun,” Mutluer says.

Mutluer found that when developing AR characters, they need to be customized to each child’s preferences.

Valmaggia agrees: “For young people, you need to develop a system with language that appeals to them,” she says. For example, if you add some senior citizens to a scene of a 16-year-old’s birthday party, the older people “would be about as saliant as a chair,” she says. In order to have clinical impact, AR and VR tools must be tailored to the user and the local context: “Avatars need to look like them,” says Valmaggia, “and it all needs to be culturally appropriate.”

References

1. Emmelkamp, P.M.G. & Meyerbr, K. Annu. Rev. Clin. Psychol. 17, 495–519 (2021).
2. Freeman, D. et al. BMJ Open 13, e076559 (2023).
3. Freeman, D. et al. Behav. Cogn. Psychother. 52, 277–287 (2024). 
4. US Health Resources and Services Administration. data.HRSA.gov https://go.nature.com/3Q4OD9R (25 April 2024).
5. National Institute for Health and Care Research. NIHR https://go.nature.com/3w0jihH (15 November 2023).
6. Freeman, D. et al. Lancet Psychiatry 9, 375–388 (2022).
7. Bakir, Ç.N. et al. Digit. Health 9, 20552076231203649 (2023).
8. Lee, A.R.Y.B., Low, C.E. & Yau, C.E. JAMA Pediat. 177, 790–799 (2023).

Author information
Mike May
Freelance writer and editor, Oak Harbor, WA, USA.

Nature Medicine 30, 1797-1799 (2024)

doi: https://doi.org/10.1038/d41591-024-00032-2