Introduction (To give context within the portfolio)
The purpose of this literature review is to explore the impact of virtual reality experiences in the context of healing and psychotherapy. First, core concepts for effective virtual reality experiences are overviewed. Then, experiences specifically designed for depression and depressive symptoms are explored. Finally, other therapeutic uses of virtual reality interventions are reviewed.
Immersion, Presence and Psychological Resonance
Determining the effectiveness of a digital therapeutic technique can be difficult. What works for one person may be less effective for others. Similarly, different technological platforms offer different design considerations. Targeting virtual reality (VR) as the intended platform for development for this project, understanding the concepts for effective experiences is necessary. In this case, two main concepts are critical, immersion and presence. Immersion is defined as, “the objective level of sensory fidelity a VR system provides.” [1]. Immersion combines both software and hardware capabilities of a VR and tethered computer system. It is a measurable representation of the visual output of a system. This includes measures such as frame-rate, resolution, refresh rate, and lighting among others [1]. Potential benefits of a highly immersive VR environment include spatial-sensory benefits as well as cognitive benefits. High immersion results in increased use of sensory processing from the user through concepts such as depth and stereopsis. Cognitive benefits include reduction in information clutter, a larger space allows for more distributed visuals.
If immersion is to be understood as the visual fidelity capabilities of the VR system, presence is the subjective counterpart. Presence is defined as, “the subjective experience of being in one place or environment, even when one is physically situated in another” [11]. Presence in general, is the subjective response to a VR environment. Presence is a multifaceted concept which includes concepts such as focus and attention. Understanding presence requires understanding a user’s individual experience of a VR environment. Two individuals experiencing the same VR environment, powered by the same computing system, are likely to rate their sense of presence differently. Similarly, an individual can experience a different quality of presence in the same environment at different times [1]. Presence is an essential concept of an VR system as it is known to predict task performance as well as simulator (or motion) sickness [11]. When presence is rated high by an individual they are more likely to engage with a task and experience lower simulator sickness [11]. Presence has also been linked to affectual outcomes. A higher sense of presence is rated with higher enjoyment of the VR experience as well as higher enjoyment of the simulated environment [9].
Aside from direct properties of VR experiences, effectiveness of a VR experience can be measured by the individual impact of their stories. In this case, Dr. Erik Goodwyn’s interdisciplinary theory of psychological resonance is especially relevant [4]. Goodwyn defines psychological resonance as:
“A characteristic quality that can be applied to any image, or narrative, that describes its mental “stickiness”, its tendency to spontaneously emerge, and/or its intergenerational staying power.” [4]
This interdisciplinary theory draws upon the cognitive sciences, religious studies, biology and anthropology among others. Resonance seeks to place a metric on the effectiveness of imagery and narratives in a VR experience. Goodwyn suggests that highly resonant experiences share common characteristics, including but not limited to, minimal counterintuitiveness, emotional evocativeness, sensory vividness and indeterminacy in time and space [4]. Psychologically resonant experiences are more resistant to change or influence from biased sources. Highly resonant experiences also tend to produce more lasting impacts and deeper believability when placebo is involved. Overall, designing with resonance in mind means the content of an experience is more impactful at the individual level and lasts beyond the length of the experience itself.
Virtual Reality and Depression
Virtual reality for treating depression and depressive symptoms is a relatively new concept. Unlike other psychopathologies (explored in the next section) virtual reality does not immediately present itself as a significantly more beneficial platform. However, some development has begun to tailor therapeutic experiences for depression in VR. Often, depression is comorbid with anxiety and interventions are built to target symptoms of both diagnoses. In a scoping review of current developments, Zeng et al suggest that VR interventions are no more effective than traditional therapy at alleviating symptoms of depression. However, they do suggest that VR interventions are effective for relieving both the symptoms of anxiety and depression simultaneously [13]. Other reviews find similar results, VR depression interventions did not improve patient dropout, but did outperform controls for relieving symptoms of comorbid anxiety and depression [3]. Despite these findings, both reviews suggest that additional work needs to be done to explore the effectiveness of depression interventions in VR as it is a newly emerging area of research.
Some prototype quality VR interventions for depression and depressive symptoms have been developed in exploratory research settings. One example has participants embody self compassionate messages they record themselves [2]. Participants, in virtual reality, would embody an adult avatar and comfort a distressed child avatar. The comforting messages are recorded as well as the movements of the participants. After this process, the participants embody the child avatar and experience the audio and movement recordings they previously produced. Results suggest a reduction in depressive symptoms as well as self critical thoughts [2]. Although this is an early development, results are promising and emphasize the importance of Yee’s proteus effect. This theory suggests changes in virtual representation impact behavior during an VR experience as well as create lasting effects after the experience [12].
Another similar prototype uses cognitive restructuring techniques to reduce the impact of unwanted or negative thoughts [7]. Cognitive restructuring is defined as, “a collection of therapeutic techniques designed to identify cognitive patterns that maintain depressed mood, and to modify these” [6]. In this study, participants wrote a severely distressing thought on paper outside of VR. This thought was then entered into the VR software and displayed as a suspended object that users could interact with. Users were able to manipulate the size, color and even gravity of the object. After some time manipulating the digital representation of the thought, participants were instructed to revisit the thought and rate its intensity and negativity. Results indicate that this exercise has a moderate effect on reducing the intensity of negative thoughts and improving mood [7].
Although it is a relatively new area of research, depression interventions in virtual reality are a promising area of research and warrants continued attention to their development. Early results indicate positive outcomes when backed by already established theories of behavioral change.
Other Virtual Reality Therapeutics
Aside from interventions focused on depression, virtual reality has been used in a wide array of other mental health interventions. Perhaps most notably, exposure therapy interventions have been used for anxiety, trauma, phobias and PTSD. Exposure therapy involves, “repeated approaches towards fear provoking stimuli” . This technique has many variants including in vivo, imaginal, prolonged, intense and more. In vivo exposure therapy involves exposure to the anxiety or fear inducing situation or stimuli directly, whereas imaginal involves thinking about the situation or stimuli [8]. Virtual reality lends itself towards a “middle ground”, a controlled and customizable environment that can vary intensity and realism. VR exposure therapy is led by Skip Rizzo’s research into PTSD interventions for war veterans [8]. This research creates various situations, of differing realism and intensity, to gradually exposure veterans suffering from PTSD to triggering situations. Results suggest highly effective and safe outcomes. Participants are able to control the intensity of the situation and tailor the virtual scenes to their individual experiences from service.
Other interventions have focused on creativity and more expressive experiences. One such example is research from Johns Hopkins’ Arts and Minds Lab wherein art therapy was translated to an existing commercial VR product [5]. This research had participants self identified with depression work with an art therapist to create art using Google’s Tilt Brush. Participants were instructed to freely create their own work using the Tilt Brush VR application and perform various pre and post test reports of their moods. Results indicated that participants that were familiar with VR found the most benefit and freedom of expression. However, generally, the experience was well received aside from the request of many participants to have a physical representation of the art they created [5]. The study also repeated the experiment with a fragrance stimulus added. Results from this unique addition found moderate improvement with positive scents (citrus, lavender, etc) however the variance of scent density in the room was quite high. Overall, this unique study shows the importance of a multi-sensory, creative intervention.
In a similar vein, another study conducted an experiment on the effect of embodied metaphor on creativity [10]. In this experiment, users were asked to complete a brief VR scenario where they broke a series of walls and doors. This embodied metaphor was said to represent breaking down “walls” of stunted creativity and cognition. Following this scenario, the experimental group completed a task that measured creativity of responses. Results indicate that the VR scenario increased creativity and originality of thought. Although this is not a psychopathological scenario, it shows another useful outcome of a VR scenario for behavioral change.
Conclusion
Although this is far from a comprehensive overview of the various methods and application areas for virtual reality intervention, it shows the breadth of this research area. Successful interventions are based on well developed and evidence based therapeutic techniques that translate well into a virtual reality environment. Much research is still needed to determine the viability of VR interventions and the components other than therapeutic technique that make them successful and effective treatemnts.
Works Cited
Bowman, D. A., & McMahan, R. P. (2007). Virtual reality: how much immersion is enough?. Computer, 40(7), 36-43.
Falconer, C. J., Rovira, A., King, J. A., Gilbert, P., Antley, A., Fearon, P., ... & Brewin, C. R. (2016). Embodying self-compassion within virtual reality and its effects on patients with depression. BJPsych open, 2(1), 74-80.
Fodor, L. A., Coteț, C. D., Cuijpers, P., Szamoskozi, Ș., David, D., & Cristea, I. A. (2018). The effectiveness of virtual reality based interventions for symptoms of anxiety and depression: A meta-analysis. Scientific reports, 8(1), 1-13.
Goodwyn, E. D. (2016). Healing Symbols in Psychotherapy: A Ritual Approach. Routledge.
Kaimal, G., Carroll-Haskins, K., Ramakrishnan, A., Magsamen, S., Arslanbek, A., & Herres, J. (2020). Outcomes of Visual Self-Expression in Virtual Reality on Psychosocial Well-Being With the Inclusion of a Fragrance Stimulus: A Pilot Mixed-Methods Study. Frontiers in Psychology, 11, 3161.
Lindner, P., Hamilton, W., Miloff, A., & Carlbring, P. (2019). How to treat depression with low-intensity virtual reality interventions: perspectives on translating cognitive behavioral techniques into the virtual reality modality and how to make anti-depressive use of virtual reality–unique experiences. Frontiers in psychiatry, 10, 792.
Prudenzi, A., Rooney, B., Presti, G., Lombardo, M., Lombardo, D., Messina, C., & McHugh, L. (2019). Testing the effectiveness of virtual reality as a defusion technique for coping with unwanted thoughts. Virtual Reality, 23(2), 179-185.
Rizzo, A. S., Difede, J., Rothbaum, B. O., Reger, G., Spitalnick, J., Cukor, J., & Mclay, R. (2010). Development and early evaluation of the Virtual Iraq/Afghanistan exposure therapy system for combat‐related PTSD. Annals of the New York Academy of Sciences, 1208(1), 114-125.
Tussyadiah, I. P., Wang, D., Jung, T. H., & Tom Dieck, M. C. (2018). Virtual reality, presence, and attitude change: Empirical evidence from tourism. Tourism Management, 66, 140-154.
Wang, X., Lu, K., Runco, M. A., & Hao, N. (2018). Break the “wall” and become creative: enacting embodied metaphors in virtual reality. Consciousness and cognition, 62, 102-109.
Witmer, B. G., & Singer, M. J. (1998). Measuring presence in virtual environments: A presence questionnaire. Presence, 7(3), 225-240.
Yee, N., & Bailenson, J. (2007). The Proteus effect: The effect of transformed self-representation on behavior. Human communication research, 33(3), 271-290.
Zeng, N., Pope, Z., Lee, J. E., & Gao, Z. (2018). Virtual reality exercise for anxiety and depression: A preliminary review of current research in an emerging field. Journal of clinical medicine, 7(3), 42.