Virtual reality (VR) has many practical applications, from surgical training to the rehabilitation of motor function, but the exploration into psychotherapy from afar is a new frontier.

The latest research and development into virtual reality could revolutionise psychotherapy, making it an attractive alternative to face-to-face therapy.

These developments are significant for those living and working in remote areas but are particularly crucial for remote mining and construction workers who are at higher risk of mental health problems.

Dr Jonathan King, a medical doctor and founder of Lysn, a telehealth mental health platform, believes virtual reality holds opportunities that are far-reaching and exciting for mental health care delivery.

“It’s definitely a growing area that has great benefits for specific treatment of conditions such as PTSD, with many companies exploring the possibility of using VR to assist PTSD victims through immersive exposure therapy.

“VR also holds opportunities for specific treatment of conditions such as phobias and brain injury training.

“There is also some great research about the impacts of VR in treating veterans for a number of issues, as well as treating several different anxiety disorders and anxiety-related problems,” said Dr King. 

However, there are limitations to uptake of virtual reality, advised Dr King, in part due to cost, ease of use and uptake of new technology by practitioners.

“Currently, VR is still an expensive tool for a customer to purchase so this poses another limitation to the technology.

“As we continue to watch this space grow, I can definitely see that if clinical outcomes are proven, it will be advantageous in large treatment centres such as clinics and hospitals.”

In a research paper published by Dr Shiva Pedram, Associate Research Fellow, University of Wollongong, virtual reality was found to be an ideal substitute for face-to-face sessions.

"While face-to-face therapy remains the optimal treatment method, we discovered VR-based therapy was more effective than Skype-based counselling.

"It can be difficult for clients to develop a strong rapport and engagement with their therapist through other technological approaches. Virtual reality can overcome these problems by generating compelling presence as well as providing richer feedback," said Dr Pedram.

To gain a better understanding of virtual reality's capability in delivering mental health treatment, Dr Pedram compared VR-based counselling sessions with Skype. It was evident that psychological therapies provided through telehealth (videoconferencing and telephone) hindered treatment progress due to the perceived remoteness to the therapist.

"We believe that virtual reality now provides the possibility for much richer, more interactive remote treatment sessions. Clients feel that they are present in the same virtual environment as their therapist and are more likely to fully engage in the therapy." 

The success of psychological treatment depends on a client's willingness to share their inner world and disclose their thoughts, feelings, problems, and history. In the study, participants appeared more open to sharing in virtual reality as opposed to Skype, and some even found it preferable to face-to-face sessions.

"There was a subset of clients in our study who reported that they were usually hesitant to attend face-to-face counselling sessions. 

"These clients reported that they were uncomfortable sharing their feelings and problems with another person due to their fear of being judged. 

"During interviews with these clients after each session, the experimenter was told that their reluctance to share their feelings with the therapist was considerably reduced in the virtual reality sessions. 

"This was primarily because they and their therapist only appeared together as avatars in a virtual world." 

Study participants also found that their virtual reality counselling sessions felt real and that they lost track of time and place.

"These compelling experiences occurred even though their interaction with the therapist was solely via avatars and their immediate environment during the session was completely computer-generated.

"In interviews after mock counselling sessions, clients confirmed their strong moment-by-moment feelings of being 'there' with the therapist, accompanied by a strong sense of engagement with them, when they were in virtual reality.

"By contrast, they reported feeling very little co-presence or social presence during the Skype sessions."

A concern in using virtual reality in the delivery of telehealth is the likelihood that the client will experience visually induced motion sickness (VIMS). These fears were unfounded in the study, as clients reported no measurable sickness after twenty to thirty-minute virtual reality sessions.

Clients in the study also felt at ease with the technology and found it as easy to use as Skype.

"These are promising findings. Skype has been around for many years, and most people are now very familiar with it. By contrast, HMD-based VR was a new experience for our participants - both for our clients and the two therapists. 

"So, the findings that both technologies were equally easy to use was positive and somewhat surprising."

The only limitation that was reported by only a few clients was a lack of accurate facial and body language feedback in their therapist's avatar. 

"The VR social networking application used in this project was programmed to generate random avatar hand and eye-movements whenever the person spoke. 

"Sometimes, hand-and eye-movements were perceived to add to the perceived realism of the interaction. Other times, they appeared to be irrelevant or distracting in terms of what the therapist was saying. 

"This particular problem arose due to technological limitations at the time of the study. Remember, in virtual reality, we are tricking the brain into believing the experience is real, and we want the user to react as if real.

"So, the main consideration should always be on how to create the right experience. Some experiences are simply not suitable for virtual reality because the technology is not ready to support it."

Until 2018, virtual reality was not a viable option for both technological and financial reasons. However, the new generation of stand-alone VR headsets have changed the market, explained Dr Pedram.

"These headsets are about $600, very easy to set up and have a great tracking technology which can considerably improve users' experience in virtual environments. Now, it's only a matter of time before industries widely start utilising this technology."

As a result, it's now possible to offer counselling using virtual reality to support the mental health of employees – particularly those living and working in regional and remote areas.

"No costly or time-consuming arrangement will be needed. All that's required is a pair of VR headsets and a quiet room. Or even in these times of pandemic where doctors are offering Skype sessions, why not use VR where we know clients will have a better experience and result?"

Dr Pedram's research is ongoing with pilot research underway to further investigate if the therapeutic experiences in virtual reality are similar to those in face-to-face counselling sessions.

"Our pilot research found questionnaire-based evidence that self-reported feelings of presence or "being there" and co-presence or "being with the therapist" were higher during virtual reality, compared to Skype clinical sessions."

Dr Pedram's research will aim to confirm these subjective reports with continuous, real-time recordings of skin conductance and cardiovascular responding.

"On average, we expect to find greater levels of positive arousal in both the face-to-face and VR sessions compared to Skype.

"We will also examine how quickly clients relax into each of these sessions – we expect that relaxation in VR and face-to-face sessions will follow very similar time courses.

"The possibilities virtual reality can offer are endless, having said that we have to create a "right" experience for users and then expect a positive outcome. Using the right technology and content for the right purpose is key."