Sam Stokes, a New Zealand-based sales manager, isn’t usually an anxious person. But there’s one thing that, as he puts it, scared the shit out of him: needles.
His aversion was severe enough to hold him back from getting routine tests. Stokes, now 40, recalls an instance in his 20s when he simply couldn’t bring himself to get a blood test. He once even drove to the testing facility to get his blood drawn, but couldn’t follow through with it. His partner (now wife) eventually convinced him to get the test, but he remembers it as one of “the most horrific” experiences he’s had.
“I kind of passed out a little bit along the way, and was sweaty and clammy and all that sort of stuff,” he said. “I just absolutely hated the whole experience.”
When the COVID-19 pandemic arrived, he knew he couldn’t let his needle phobia hold him back. Even watching the news became difficult, as stations regularly ran stories about vaccine developments.
“Every third story was an image of a needle, and that just freaked me out,” he said.
But by the time Stokes became eligible to get the vaccine, he didn’t feel a pinch of anxiety. No clammy hands, no cold sweats. Nothing.
Stokes overcame his phobia through virtual reality, a buzzy technology that industry giants like Meta and Sony believe could be the future of gaming and online socializing. With Apple expected to announce its first headset this year, 2023 could be a landmark moment for the technology.
The idea of using virtual reality to ease anxiety and overcome phobias isn’t new; it’s been studied since the 1990s. The arrival of modern VR headsets like the original Oculus Rift and HTC Vive in 2016 reignited conversations about how the technology could improve mental health care.
But in 2023, despite the pandemic shining a spotlight on stress, anxiety and burnout, it feels like we’re still talking about VR’s potential as opposed to its impact. We’re still far from a world in which strapping on a VR headset to conquer your fear of crowds is as common as calling your therapist before a subway commute. And it’s not because of technological shortcomings. Rather, high costs, VR’s slow adoption and a lack of awareness about VR therapy are to blame.
“I actually thought we’d be farther along by now,” said Dr. Barbara Rothbaum, associate vice chair of clinical research at the Emory University School of Medicine, who conducted a study published in 1995 examining how VR could be used in psychotherapy. “I thought that more people would be using it for therapeutic interventions.”
Stokes, for example, only tried it because he saw a TV news segment about a study being conducted by the University of Otago in Christchurch, New Zealand, and oVRcome, maker of the same-named VR app meant for addressing phobias.
“Unlike maybe some other fears, I had an end date,” Stokes said. “I knew that I had to get a COVID vaccination. So I knew that this was my chance.”
The evolution of VR
In 2023, you can attach a Google Cardboard headset to your mobile phone for less than $20 to experience VR. It certainly wasn’t like that when Rothbaum and her colleagues were working on their study, which was published in the American Journal of Psychiatry in 1995. Researching whether VR would be an effective way to treat a fear of heights through exposure therapy required a $150,000 computer and a headset that cost around $16,000 back then, according to Rothbaum.
That computer needed to be set up in a separate room not only because of its size, but also so it could be kept cool, she says. While the patient wore a head-mounted display in a small room with Rothbaum, she’d use an intercom to communicate with a graduate student operating the computer.
“It was a very big operation,” she said.
Since finding a virtual reality headset wasn’t easy in the 1990s, Rothbaum worried that she wouldn’t be able to continue her research when one of her favorite models was discontinued.
“I thought, well, that’s the end,” she said. “That’s the end of our work.”
Luckily, that didn’t happen. The market was small, but other headsets began to crop up, often at lower prices. Rothbaum has collected so many of these headsets over the years that she has a museumlike display case in her home office filled with them.
“It was mainly the resolution,” said Rothbaum, when asked why she preferred some headsets over others. “But also, if it was not comfortable for a patient to wear for 30 minutes, then that was going to be hard to use.”
Today’s VR headsets still have usability issues of their own, such as short battery life and limited compatibility with prescription glasses. But there’s no denying they’ve come a long way from the system Rothbaum used in the ’90s. Facebook parent company Meta currently dominates the virtual reality space, with 81% of the market as of the fourth quarter of 2022, according to Counterpoint Research.
Its Quest 2 headset costs $400 and doesn’t require an external computing device. That alone represents a significant leap even from 2016-era headsets like the first-generation Oculus Rift and HTC Vive, both of which had to be tethered to powerful computers to fuel games and apps. Sony also just released the $550 PlayStation VR 2, which boasts a vivid display, haptics and eye tracking technology but must be tethered to a PlayStation 5.
A rise in demand for immersive at-home entertainment during the pandemic, combined with the hype surrounding the metaverse, has resulted in more attention being paid to virtual reality.
“It’s still going to be probably a decade out before we have a fully realized metaverse,” said Ramon Llamas, a research director for market research firm The International Data Corporation. “But in the meantime, we’re going to have a lot of fun and … interesting innovations coming along for VR.”
Trying VR therapy
Many studies and research papers have been published since Rothbaum’s. A scoping review from 2021 examined 19 studies that used virtual reality exposure therapy to address specific phobias. Twelve reported that VR was effective at decreasing anxiety.
It’s easy to understand why, once you try it for yourself. That’s why I asked Dr. Howard Gurr, a New York-based psychologist who offers virtual reality therapy, to demonstrate the software he uses with his clients, which is provided by a company called Amelia Virtual Care.
After launching the app and placing my phone in the VR headset, I was transported to what would usually be a very anxiety-inducing situation for me: getting behind the wheel. I’ve been living in New York City for more than a decade, which means I also haven’t driven a car in about 10 years.
I’ve always been a nervous driver, so living in the city has felt liberating, since I can rely on public transportation and Uber to get around easily. But just as Stokes had to confront his phobia to get vaccinated against COVID-19, I’ll have to address mine if I want to buy a house in the suburbs with my husband and start a family.
Hitting the road virtually is no substitute for the real thing; my simulation was animated, and I didn’t have a physical steering wheel or gas pedal. There was no way for me to accelerate, brake or choose when to merge into a different lane. I felt more like I was along for the ride than in control, but it felt immersive enough to provoke some nervous reactions.
For example, I experienced that familiar pang in my stomach when I noticed a truck approaching in my side mirror. Even though I wasn’t in a real car, I felt compelled to keep my eyes fixated on the road in front of me.
I didn’t even see the other virtual passengers in the back seat until a few minutes into the simulation, because I was so focused on the highway. The pouring rain and sounds of trucks and cars zipping by almost made me forget I was sitting in my office, though it didn’t quite feel like I was behind the wheel either.
My experience with Gurr was administered remotely on a headset that costs less than $20 and that used my smartphone as the engine. The goal behind a setup like this is to make the technology as affordable and accessible as possible.
But more robust setups also exist, such as the one used by Dr. Joseph Hirsch, a New York-based psychologist who’s published research papers on virtual reality therapy in the American Journal of Clinical Hypnosis. He tells me he’s used a vibrating platform with speakers to more accurately simulate the feeling of turbulence when working with patients who are afraid of flying.
Not just phobias
Treating phobias seems like a natural application for virtual reality. Boarding a virtual airplane or staring down from the top of a digital skyscraper is much more vivid than imagining it. Gurr says this level of detail and immersion speeds up the process of overcoming a phobia.
“I could see patients [and after] seven, eight or nine sessions, they’re done,” he said. “You can’t do that in traditional therapy.”
And then there are cases where virtual reality provides a sense of escapism or a new type of comfort zone. Monet Goldman, a licensed marriage and family therapist based in California who offers VR therapy, understands this better than most.
He remembers one session in early 2022 when virtual reality was particularly impactful. He was counseling a child over a video call who had completely shut down and was giving only one word answers. But that changed once Goldman and the child began playing a game in VR. Goldman says he was “completely different.”
“These are the things he’s the best in the world at, and now he gets to reveal that,” Goldman said. “He gets to teach me that, and I get to witness this. And it kind of helps their self esteem, their sense of achievement.”
Even those who are well-versed in VR are finding new ways to use it as a stress reliever. Anais Riley, better known by her alias Naysy, who’s garnered millions of followers across TikTok, YouTube and Twitch, has used the popular VR dance game Beat Saber to cope with work-related anxiety. It provided just what Riley needed to combat her stressors: physical exercise, a sense of accomplishment, escape from the real world and the opportunity to tap into her childhood interests of music and dance.
“I really was just loving playing the game and seeing myself get better,” she said.
But virtual reality isn’t a magic wand for making anxiety and phobias disappear. It’s merely another resource therapists can use when providing exposure therapy, a technique that helps people overcome fears by exposing them to phobia-inducing stimuli in a safe environment.
Rothbaum likens it to using a real elevator to help address a patient’s fear of elevators. “I’m trained in exposure therapy, and that elevator, I’m going to use it in a different way for every different patient,” she said. “So you know, it’s just a tool. It’s not elevator therapy.”
VR is still waiting for its breakout moment
The biggest problem is that people simply aren’t using VR on a regular basis. If VR headsets were nearly as ubiquitous as smartphones, therapists would likely be lining up to find ways to incorporate them into their practice. But right now they have little incentive to learn about or invest in VR if their clients aren’t using it.
“The bottleneck has always been the cost,” says Dr. Albert “Skip” Rizzo, research professor at the University of Southern California’s Department of Psychiatry and School of Gerontology.
Shipments of VR and AR headsets are estimated to have reached 9.7 million units globally in 2022, according to statistics from IDC. To put that number in perspective, 300.3 million smartphones were shipped worldwide in the fourth quarter of 2022 alone, according to IDC, even though the market experienced its largest ever single quarter decline.
The arrival of Apple’s long-rumored headset, which could debut in June, according to Bloomberg, may help usher in that breakout moment for VR. The head-mounted computer will likely be expensive; Bloomberg reports it could cost around $3,000. But Apple’s history of popularizing new technologies like the smartphone, tablet and smartwatch have set the expectation that it could do the same for virtual reality headsets.
“Apple has a way of driving the tide that lifts all boats,” said Llamas. “It brings attention, and it brings legitimacy to many of the markets that it enters. And I don’t think VR will be different.”
It’s difficult to tell how many therapists and mental health professionals currently offer VR services, but there is some data that can provide a clue. Amelia Virtual Care, which provided the software I used during my experience, has been used to help treat more than 20,000 patients, says founder Xavier Palomer. The software is used by more than 2,000 mental health professionals around the world, according to a company press release.
Adam Hutchinson, founder of oVRcome, which provided the software used in the clinical trial Stokes participated in, says his programs have been used in more than 30 countries.
Gurr also maintains an informal directory of therapists who offer VR services. Roughly 60 practitioners are listed on his website, the majority of whom are located in the US, where psychologists typically need to meet state-specific licensing requirements. The Association for Behavioral and Cognitive Therapies’ directory lists 40 VR-equipped therapists.
These numbers pale in comparison to the nearly 700,000 behavioral health specialists in the United States alone, according to data from The George Washington University’s Behavioral Health Workforce Tracker. Of that total, 539,714 are counselors and therapists.
“Virtual reality, even though it is effective, is still in its infancy,” said Gurr. “And clinicians are kind of reluctant to pick up a technology that either they don’t understand or weren’t trained in.”
Aside from VR being relatively scarce, there’s also the learning curve issue. Mental health professionals must take the time to understand virtual reality and learn how to apply it to their patients’ or clients’ needs.
Even someone like Goldman, who grew up playing video games and fondly remembers his Gameboy, practices VR games on his own time so that he can properly engage with his clients.
“[There’s] a lot of, I guess you could say, training and education outside of the game itself,” Goldman said.
The companies trying to make VR therapy more popular
Hutchinson recognizes that it might be quite some time before the general public — including therapists — adopts VR on a regular basis. That’s why he began with the device most people already rely on every day: the smartphone. Though oVRcome also provides tools that therapists can incorporate into their practice, the company started by distributing VR therapy programs developed by clinical psychologists that anyone can use without a therapists’ supervision.
“That was the goal with oVRcome, was to make treatment for these anxiety disorders using virtual reality exposure therapy easier to access and far more affordable,” Hutchinson said.
Participants are exposed to a low-anxiety virtual environment when the program starts and gradually progress to more direct circumstances. In Stokes’ case, for example, one of the first stages put him outside a virtual vaccination tent, while the final session had him sitting with a nurse ready to administer an injection.
“We really wanted to model how exposure therapy was provided in the clinic,” Hutchinson said.
Amelia’s software, which I used during my session with Gurr, is designed to be used under the supervision of a mental health professional. The company’s offerings include a VR kit that comes with a headset and an electrodermal response sensor for measuring a patient’s sweat response, a VR software platform with access to more than 100 virtual simulations and an app for administering VR therapy remotely. The company also provides training and support materials like an introduction course, tutorials, manuals and marketing guides.
Xavier Palomer, the founder of Amelia, came up with the idea around 2013 because his friend was afraid of flying. The company was founded in 2014, but Palomer says it hit an inflection point around late 2016, early 2017 as VR hardware like the Samsung Gear VR became more popular. The pandemic also generated more awareness around mental health and self care.
“We are more open to talk about it,” said Palomer. “To look for solutions, to actually ask for help.”
According to Rothbaum, conventional wisdom says it takes 20 years from when a study comes out for that technology to make its way into public use. If that holds true, VR should’ve already hit that point. But Gurr sees things a little differently. That timer didn’t start in 1995 when Rothbaum and her colleagues published their study. It began when modern VR headsets became cheaper and more widely available.
“Even though virtual reality has been around for a long time, I’m starting the clock at 2015,” he said. “Which means we’re only in there for seven or eight years.”
Although Stokes was familiar with VR, he never considered using it to address his phobia of needles until he came across the oVRcome study. In fact, he wasn’t going to seek help for his phobia at all. But now the thought of getting a vaccine or a blood test doesn’t bother him in the slightest.
“If I had a needle sitting on my desk right now, I would be completely comfortable,” he said. “It’s actually remarkable.”
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