Once synonymous with gaming, virtual reality (VR) has made inroads in recent years in a wide range of applications — particularly in healthcare, where the ability to create immersive, virtual worlds has led to some remarkable advantages for patient care.

Daniel Freeman, a professor of Clinical Psychology at the University of Oxford, has conducted research into the use of VR as a treatment tool for a range of mental health conditions, including paranoia- and anxiety-related disorders. (His work has involved investigating the use of VR therapy for overcoming fear of heights and of needles, for instance.)

Freeman founded OxfordVR, a spinout firm (recently merged with US-based BehaVR), which is responsible for gameChange, a VR-based treatment for severe psychosis-related agoraphobia that’s currently in trials with health services in the UK and US. The gameChange treatment involves the use of VR by house-bound patients to simulate everyday situations such as a café, pub, or bus trip. It was used in a trial involving hundreds of patients — thought to be the largest randomized, controlled trial involving VR mental health treatment so far — with the results published in The Lancet indicating that the automated VR therapy led to significant reductions in distress related to everyday situations.    

Daniel Freeman, professor of Clinical Psychology at the University of Oxford.

In a recent conversation with Computerworld, Freeman discussed how VR devices and applications can be used to provide effective treatment to patients at a time when health services are struggling to meet demand. In certain cases, this includes the ability to automate healthcare delivery with the provision of VR headsets for patient care – an increasingly realistic prospect for providers due to recent advances in the technology and lower costs.

This interview has been edited for length and clarity.

How can VR be used as a tool for mental health or mental illness treatment? What has your research shown? "There are two key aspects of VR that could be hugely beneficial for mental health care. The first point is that VR is inherently a very therapeutic medium. The fact that people know it's not real enables them greater psychological flexibility; they can make new learning that's beneficial for their mental health. Rather than the awareness that it's not real causing a problem, or dispelling the benefits, this is actually really useful in psychological therapy. Many of the people we see are very caught up in their thoughts, and it's actually a medium in which one can get a bit more distance from [their inner monologue] and think anew, and learn anew. So it's inherently very therapeutic.

"The second key point is that there's potential to automate the provision of psychological therapy in VR, and thereby help close this large gap between the number of people who need help and the current service provision. So I think it's a way to scale up really powerful psychological therapy."

What are the greatest uses for VR mental health treatment in the short term? "...There are very few areas where it couldn't have a benefit. Historically, what people have often done for anxiety disorders are 'exposure’ type approaches, which is perfectly sensible. But we're also using it in other areas now. For example, we [University of Oxford researchers] have been doing some work around enhancing people's self-confidence and psychological well-being. There are loads of uses.

"Obviously, there are areas where one wouldn't use it; at times of particular crisis you want in-person interaction with a skilled professional. There are a few places it doesn’t make sense, but there are lots [where it does].

"The question is having some good exemplars that actually benefit patients and the system, and get implemented. And I think we're at that stage of, can we actually get this implemented into routine services? And I'm definitely of the view that VR will become part of mental health care — it just makes so much sense. The question is really how quickly it is going to come."

To what degree has VR been proven an effective tool for mental health treatment? "For the treatment of anxiety disorders, I think the evidence is strong.... Other areas, it just hasn't been done yet. [The research is] still rather niche. There are very few people that do this work. And then in terms of automated psychological therapies, hardly anyone does that. Historically, it's always been that a therapist is there providing the therapy, and there are VR environments provided as part of that. That's been the traditional model for that was 25 years.

"The point I’m trying to push on is that, with the new consumer kit — better software and better hardware — you can do automation. That's a lot more programming work, it’s a huge endeavor, but the advantage there is, if you try it, then you know it's going to work repeatedly. Whereas, if it's dependent on a therapist, then that always depends on the therapist.

"In terms of the evidence base, the trials have principally been around treating anxiety disorders, and evidence there is good."

You also co-founded the spin-out Oxford VR and helped create the gameChange treatment product. Can you tell me about gameChange and the benefits for patients and health care services? "It is about providing an automated VR treatment to help people who are largely housebound get back out in the world again.

"This is funded by the National Institute of Health Research. There were multiple partners, including University of Oxford, Oxford Health, OxfordVR, and others, too. It was a large-scale, ambitious project to basically develop a treatment for people with psychosis, show that it works, and begin to implement it in services.

"We did a year's design process with people with this experience, targeting the anxious withdrawal that many patients with psychosis have. We developed gameChange, and tested it in a randomized control trial with several hundred patients with psychosis. Since then, we've been working on potential implementation.

"We've done it really fast: historically, designing and testing a treatment and getting into services takes a long, long time. We are trying to speed that up, and do it for VR. We've made good progress, we’ve got the treatment, we know it works for people who are largely housebound, and really where we're at now is the implementation stage.

"It's currently under review by NICE — the National Institute for Clinical Excellence, the group that sets the guidelines in the UK — and it's also being used in one or two NHS Trusts. At the moment, we've got pilot sites both in the UK and the US."

The gameChange app uses virtual reality to allow house-bound patients to simulate everyday situations.

What have the results been so far? "We did a very rigorous trial, in fact the largest trial that there's been of VR in mental health. It showed that, for the most severe patients who find it difficult to leave their homes, it has a large effect on reducing avoidance...that persists months and months later. The intervention is provided over six weeks, and nine months later that subgroup still has benefits. So, it’s the patients with the most complex difficulties — the group that most needs treatment — that it works really well with, which is fantastic."

What is the view from health authorities or regulators about using VR for this type of treatment? How open are they in the UK and in the US? "I think there is a great appetite. The issue really is changing any healthcare system; implementing a new treatment is hard, because they've got to put investment in and change things. Often, finances are tight. It's like any change in a healthcare setting: it takes time. But there is great enthusiasm, so I am really hopeful. It will come, it's just a question of when. The support we've had from research funders and NHS leadership has been very good."

Can you tell me a more about the benefits from the perspective of a health service? "There’s an awareness that there needs to be greater provision of evidence-based psychological therapy, and this is a route to do it. Many patients [with psychosis] often do not get the psychological therapy, even though it would be helpful. This would be one route to do it in a way that is both effective and also cost-effective.

"Another way to put it, for gameChange, we still have staff support, but rather than being highly skilled and scarce therapists, there's a wider workforce, including peer support workers, assistant psychologists — a greater range of the the mental health workforce — that can support it. It often takes less time than other standard treatments.

"So it's basically improving access to psychological therapy via a wider workforce, requiring less time to deliver."

Are there drawbacks to reducing reliance on in-person treatment? Does interaction with a therapist have a benefit for patients, for example, and the treatment effectiveness? "We still need more psychological therapists; this isn't about replacing therapists, it’s about expanding provision. Some people do want face-to-face contact, but there are some who don't particularly want that. And also  that's not the only route to overcome mental health problems. So, for some treatments, [in-person treatment is] a key aspect, but for other approaches it's other aspects that are important. It's not the only route to make change. Nor do we want this to replace therapists. That's not not the aim...."

What other challenges in making VR more widely available for mental health treatment? How can this scale to delivered treatment for a large number of patients on a regular basis? "I think it’s going to need to be one of the recommended treatments. So, it's got to pass the clinical trials test for it to be recommended. But even then, you've got to have implementation plans within healthcare settings to do it, and that does involve some changes to current service provision, and that takes work. What we're probably headed to is, I suspect, a number of demonstration sites to do it.

"But there are no large barriers here, it's just like with any other treatment. It just takes time to change services a bit. With the tech we use, we're not relying on NHS health IT systems, we do it 'standalone,’ so that's easier. There's obviously information governance and security stuff that one does, but there are no huge challenges here. It's just the sort of hard grind of getting change in a healthcare setting really at the moment."

What’s your view on the maturity of VR headsets? There’s been a lot of investment in the development of these tools and the technology has become more accessible, but there are still some concerns about comfort and usability. "Well, I started using VR in 2001 when the headsets were pretty much handmade and [cost] around £25k, plus all the other tracking systems, computers, and support that you needed around it. So the new standalone headsets are excellent, actually.

"We're at the stage now where, in some of the development work, we are leaving headsets with patients in their homes, because the headsets are affordable enough to do that, and also because it’s easy enough to use. We've been doing work with younger people who've been diagnosed with psychosis and leaving headsets at home, and that's worked really well.

"When we did the gameChange trial, we were still having to set up sensors in the room and stuff like that. We didn't have standalone [devices], so that has made a huge difference. It feels that the kit is really good enough to do it now.

"There's obviously the general comfort of having a headset on your head for an extended period of time, but actually the current headsets are working well at the moment. I think the tech side is in a good place for implementation."

Do you get a sense of the level of acceptance from patients using the technology? "Oh, they love it. It's the most popular treatment. Obviously, a lot of people haven't used VR before, so we're seeing people try it for the first time and they're amazed about how immersive it is. You can see the shifts in mood in a session. And now if you're able to say you can keep [the device] for a couple of months, it goes down really, really well. People feel valued, but they're also enjoying the tech, so the acceptance rate is really high. It's obviously not for everyone — some people don't like tech — but on the whole, the uptake has been really high.

We’ve discussed automated delivery of treatment. What potential do you see around generative AI in combination with VR? Could this be used in conjunction with VR for more realistic interactions and experiences?

"I think that's going to be the next wave. It could obviously help in social settings in terms of the the way [virtual interactions] can seem much more realistic. There’s the potential now for conversations — as long as you've got certain guardrails around that — I think that's going to be the next frontier, using that within VR.

"With a virtual therapist in automated form [such as in the gameChange treatment], that could improve it. Now we are using standard scripts and we're working on that and thinking through the logic, but of course there's a lot of learning and improvement that could be done by AI. So yeah, that will happen I'm sure."

Is that something that you're Investigating In terms of your research? "People are looking at it carefully. At the moment, because we already know enough to produce some really good stuff that doesn't use it, we're focused on that. But we will certainly be investigating it."