This article is part of VICE Gaming's Mental Health Bar series – find more here.
In 2016, virtual reality is exciting. Be it dogfighting through space in EVE: Valkyrie, defusing bombs in Keep Talking and Nobody Explodes, or making a complete arse of an operation in Surgeon Simulator, the past few years have seen the tech finally catch up with the vision. If you're old enough to remember the early 1990s, you'll likely recall similar fanfare – not to mention some excruciating hyperbolic advertising – that ultimately failed to deliver. The then new-fangled "transformative technology" was going to change the world, we were told – but underperforming hardware coupled with extortionate pricing and a lack of applications instead left the majority of us turned off and disenchanted.
For many, virtual reality as a medium and a concept had failed. For clinical application, though, it was enough to get the idea of VR-inspired treatment rehabilitation off the ground. "It was sufficient, though costly, difficult to create and not easily modifiable and so what ended up happening was maybe a hundred or so dedicated clinicians hung in there for the last 20 years and gradually the technology got better," explains psychologist Albert "Skip" Rizzo, the director of medical virtual reality at the University of California's Institute for Creative Technologies.
Rizzo researches the design, development and evaluation of virtual reality systems via clinical assessment, treatment rehabilitation and resilience. Although primarily focused on post-traumatic stress disorder (PTSD) in relation to the military, he and his colleagues have addressed social skill training in people with autism; cognitive tests in VR for kids with attention deficit disorder; and the development of game-based rehabilitation applications for people in the aftermath of a stroke or a traumatic brain or spinal cord injury, to name but a few examples of he and the ICT's work.
"PTSD and anxiety disorders are characterised and propagated by avoidance – [but then] the brain of that person doesn't learn." – Albert Rizzo
Through this work, Rizzo champions the idea that placing patients in relatable video game-like scenarios can be beneficial in helping them engage with treatment. "I was working with brain injured patients back in the 1980s and '90s and finding that it was hard to engage them in this repetitive drill and practice brain training work," says Rizzo. "But when you deliver that kind of stuff in a brain-like context – like having them play SimCity, which is an engaging game but requires executive function, multi-tasking, memory, attention all brought together – all of sudden you see patients that you couldn't motivate for more than ten minutes now deeply engaged in a cognitive activity. With the PTSD work, that's one element and it's a well-matched one for VR."
While VR has potential to help patients with physical injuries, the benefits it has and continues to have for people with mental health issues, like PTSD, are plentiful. Rizzo explains that much of his work is tied to exposure therapy - an evidence-based form of treatment for addressing anxiety disorders. In its traditional format, exposure therapy relies on imagination and (in the case of PTSD) the patient to narrate their traumatic experience as if it's happening in the present. Naturally, this can be a very painful process, however guided by a therapist in a safe setting, the idea is to confront your fears rather than avoid them.
"PTSD and anxiety disorders, like phobias, are characterised and propagated by avoidance," says Rizzo. "When you avoid something in fear, or it makes you feel anxious, you get a temporary sense of relief, and that reinforces continued avoidance. The brain of that person doesn't learn that was then, this is now, and that things that are reminiscent of the trauma are no longer going to hurt you, and you're in a safe environment."
VR is essential to this process because, although evidence-based, exposure therapy is not an exact science and not everybody is good at visualising. Virtual reality, then, allows patients to be immersed in simulations of what has traumatised them, at a gradual pace, and helps them confront and process these difficult emotional memories and, crucially, get beyond them. War-based series such as Call of Duty or Battlefield might perpetuate a cathartic revenge fantasy, suggests Rizzo, but the idea here is to get patients to deal with their anxiety by placing them in a context that resembles a hurtful scenario, but at a pace they can handle.
The advent of affordable mobile headsets, such as Samsung's Gear VR, also means there is scope to decentralise the process of mental health treatment, which in turn could help it reach more people. Earlier this year, University College London and the Catalan Institution for Research and Advanced Studies published an academic paper that detailed how VR therapy could reduce depressive symptoms by boosting feelings of self-compassion. Via three weekly eight-minute sessions, the pilot study examined 15 adults aged between 23 and 61 with depression.
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The group used virtual reality headsets to see from the perspective of a life-sized avatar, before being asked to express compassion towards a distressed child. Afterwards, the patients embodied the child and were made to listen to the adult avatar repeating their recorded words of compassion back. One month on and nine patients reported reduced symptoms of depression, while four experienced "a clinically significant drop in depression severity" following the therapy. Some patients also said they were less self-critical in real-life situations afterwards.
It's worth noting that this particular study was operated without a control group, and of course 15 people is by no means a large sample, however self-criticism is often a central tenet of depression. It would therefore be fascinating to see this kind of study undertaken by a larger, further-reaching group of people.
"Research shows that activating fear and anxiety, in a safe place, is the only thing that makes it go away." – Albert Rizzo
"Now, we're all finally here looking at VR running off a mobile phone, and looking at high-fidelity headsets like the Oculus or a Vive that blow away the head mounts of ten years ago, that cost tens of thousands of dollars," says Rizzo. "So, we've got the technology and we've got 20 years of research documenting it all. When a clinician can open their desk drawer and open up a headset like that, no computer, and just hand it to a patient and have a wireless connection so that their laptop or iPad or whatever device they're using can actuate the scenario and can collect the data of the interaction, now you've got a tool that by all intents and purposes should be very adoptable by any clinician."
The other end of this financial scale saw the Canadian government purchase the latest version of Rizzo's Bravemind – a PTSD treatment programme that began life as a total conversion mod for 2004's Full Spectrum Warrior, which includes a vibrotactile platform and a scent machine that simulates diesel fuel, garbage and gunpowder – for $17,000 each in 2014. "To engage the user, sometimes that multi-sensory experience really adds a lot," adds Rizzo. "The vibrotactile platform is a cheap circus trick that stimulates multi-modal sensation because it's very inexpensive – we're using four subwoofers which cost 50 bucks a piece, a little amplifier and we run all the sound into it."
While every individual seeking treatment for issues of mental health is different, Rizzo is of the view that supportive counselling on its own doesn't work. "The idea that doing supportive counselling alone where people are told, 'Don't worry about that stuff in the past, let it go, let's worry about the future' – that shit doesn't work, to be quite blunt. Therapists don't like to do it because they don't want to feel like they're arousing anxiety in patients, and no therapist wants to make their patients feel uncomfortable. But in the course of addressing this very difficult clinical condition, the research shows that activating the fear and anxiety component of it, in a safe place, is the only thing that makes it go away. It's hard medicine for a hard problem."
Rizzo's view here can't be applied universally – however, it can't be argued that the potential VR shows today, beyond simply being a video game peripheral, isn't exciting. Depression, anxiety, phobias, and of course PTSD, are but a few of the areas that VR technology is already being applied in. Advancements in the technology's capabilities, not to mention wider affordability, could serve to help many people – many more than it already has over the past 20 years.