Jane walked into the waiting room and found a line of grim, metal chairs staring back at her. She could feel her heartbeat quickening, her stomach tying itself in knots. She expected her social anxiety to creep up on her during her job interview, but the waiting room felt premature. She sat next to another prospective employee who was nervously twiddling her thumbs and tapping her feet. “Maybe anxiety is contagious,” she thought to herself.
A tall, blonde woman in a sleek black dress emerged from a door across the room and called her name. Jane followed the woman down a never-ending hallway into a cold, crowded office where a woman sat, tapping her pen against her desk, a tint of frustration in her eyes. “You’re late,” the woman sneered. Jane couldn’t take it anymore, she tore the virtual reality (VR) headset off and took a seat across from her therapist, ready to run a play by play.
While Jane is a fictitious patient using a VR game in development to treat social anxiety, many real patients use VR experiences in psychiatrists’ offices and at home. Serious video games garnered attention and support following the FDA approval of the first prescription video game, EndeavorRx, for attention deficit disorder (ADHD) in 2020. VR is just the latest trend in digital therapeutics.
“The technology caught up with the vision. We're not hamstrung by super expensive, and overly complicated, unusable systems. We can start to develop these things and get it out the door to real people,” said Albert “Skip” Rizzo, a VR therapeutics researcher at the University of Southern California.
Researchers like Rizzo develop VR experiences to aid in treating post-traumatic stress disorder (PTSD), ADHD, and autism. Growing data from clinical trials show that VR, in combination with other therapies or medications, can effectively treat many psychological disorders.
“The VR that I imagine is the true simulated reality that we dream about or read about in science fiction books. It's not just what you see, but what you see, hear, smell, feel, how you move to give you truly a sense that you're in another environment that feels real,” said Adam Gazzaley, a clinical neuroscientist who directs the Neuroscape Center at the University of California, San Francisco and co-founder of Akili Interactive Labs. “The hypothesis is that if you present digital medicine in that environment, the outcomes will be enhanced.”
A new endeavor
By 2008, Gazzaley had spent nearly two decades studying aging. He used functional magnetic resonance imaging (fMRI) to understand the underlying changes in the aging brain that led to a decline in cognitive control. Cognitive control refers to the ability to process information and focus on the information most relevant to the current goal, a function that is critical when multitasking. Impaired cognitive control can lead to problems with memory, understanding language, and processing emotions.
“We didn’t really have any tools to help people, and that just started getting more and more frustrating as my career went on. I didn’t really want to spend the rest of my life just collecting publications and not really making any meaningful difference,” said Gazzaley.
He started looking for ways to combine his experience and expertise in aging and neurological attention systems to develop solutions. As a physician, he was trained to look for a pill, but he didn’t think drugs would alleviate attention deficits in aging people.
“I went back to my roots as a graduate student, thinking about neuroplasticity and how we might be able to harness the ability of the brain to learn to modify its responses and optimize its processing in response to experience,” said Gazzaley. “I thought of a video game.”
Gazzaley grew up playing a variety of video games such as Atari games and “anything Star Wars.” But as an adult, he is more drawn to cinematic style video games with a rich story.
His interest in the artistic aspects of video games, particularly Star Wars-inspired ones, led him to Matt Omernick, who was the executive art director at LucasArts, a video game company founded by George Lucas, co-writer, director, and producer of many of the Star Wars movies. Together, the two designed the predecessor of EndeavorRx: NeuroRacer (1).
In the game, players race a car down a curvy road while signs continuously pop up in front of them. The players need to press a particular button when they see a specific sign while still safely steering their car. This game tests the player’s multitasking skills, a facet of cognitive control.
Players who were 60 to 85-years-old were worse at the game than players in their 20s. However, after playing the game for 12 hours over the course of a month, the older group became better at the game than the 20-year-old study participants playing the game for the first time. The skills the older players learned from the game seem long-lasting; they proved to be better multitaskers than before playing NeuroRacer even six years later (2).
The older players improved in skills related to cognitive control that the game did not directly address such as memory and attention (although these skills returned to baseline within six years).
The game didn’t only change behavior; it also changed the brain. Based on electroencephalograms (EEGs) taken while the participant played NeuroRacer, neural activity in the brain responsible for cognitive control strengthened, likening that of the younger study participants. These changes in the brain were still present six years later as well.
Gazzaley and Omernick went on to found Akili Interactive Labs, where they modified NeuroRacer to build EndeavorRx, which uses similar mechanics to improve cognitive control in children between ages 8 and 12 with ADHD. After conducting several clinical trials including nearly 600 children, researchers at Akili Interactive Labs demonstrated that children who played the game saw significant improvements in attention. The FDA approved the game, which can now be prescribed by a physician.
Into the third dimension
Gazzaley still works on 2D video games, but he is slowly entering the third. He tested the assumption that VR would increase engagement and therefore improve patient outcomes. In a study published in the Journal of Cognitive Neuroscience, he reported that VR increased player engagement, amplifying the digital therapeutic’s positive effects (3).
For this study, Gazzaley split 40 participants into two groups; one completed an attention-based task on a 2D monitor and another used a 3D headset to determine which version was more engaging. The task was simple. The participants were immersed in an underwater landscape. If they saw a sunfish, they needed to press a specific button on the controller. But if they saw any other type of fish, they shouldn’t press anything. With success, the game gets more and more challenging.
Participants who played the game using a VR headset responded more quickly when they saw a sunfish, indicating they were likely paying closer attention. The researchers also used electroencephalograms (EEGs) to measure the participants’ brain activity while they played. Participants using the VR headset showed more neural activity while they played than participants using a 2D monitor.
“This gives us a little bit more inspiration, ammunition, and hypothesis generation in terms of thinking that a therapeutic video game that was delivered in a more sensory immersive environment may have greater outcomes because attention is being deployed at a higher level. And that is exactly one of the reasons why VR is interesting to us,” said Gazzaley.
Gazzaley is particularly interested in interventions for attention since his research interests have always focused on facets of cognitive control surrounding attention deficits.
“Attention is just fundamental to everything. All other aspects of cognition rely on attention, from memory to decision making, our emotional regulation, our ability to feel empathy and compassion, language. Everything relies on attention. If attention is fragmented, and not able to be sustained, all those things suffer,” said Gazzaley. “By being able to improve attention abilities, there's this potential to have a wide positive impact.”
Gazzaley’s most recent attention-worthy endeavor is the development of a therapeutic VR game called Labyrinth that helps improve attention and long-term memory (LTM) in healthy older adults.
In the game, players navigate through the winding streets of 3D urban and rural landscapes completing tasks such as finding objects. As the players progress through the game, the areas become more challenging to navigate and the tasks harder to complete.
In a recent study, Gazzaley and his collaborators recruited approximately 50 participants with an average age of 67 to play either Labyrinth or an adventure game on a handheld device for 12 hours over a four-week timespan. The researchers used an algorithm to determine how well the players navigated their respective games and determined that Labyrinth players navigated their environments more efficiently.
The participants also completed memory assessments before and after participating in the study. One such test, called a mnemonic discrimination task, involved showing participants a set of pictures that they need to remember. Then the participants view another set of images containing the original images along with new ones. The participants then state if the image is old, new, or similar to an original image. For example, if the participants first saw a picnic basket and a hammer, those would be “old” when shown again. An image of a rubber duckie would be “new,” and a picture of a picnic basket that is blue instead of red would be “similar.” Mnemonic discrimination worsens in adults as they age.
Participants who played Labyrinth were better at the mnemonic discrimination after they played the game, while players who played the control game did not improve. The Labyrinth players improved so much that their scores on the mnemonic discrimination task matched those of young adults tested in a previous study.
“That was amazing because there’s not really many examples in the scientific literature at all in any population that have actually improved memory abilities that don’t rely on strategies like memory tricks. This is no trick. They didn’t learn any strategy about how to memorize things,” said Gazzaley. “We’re happy with what we saw. Now, there’s a lot more work to do.”
Step into my office
Michelle Newman, a psychologist from The Pennsylvania State University, uses VR experiences to tackle another problem: social anxiety disorder (SAD). Newman treats patients with SAD regularly, so she understands the challenges. People with other phobias often undergo exposure therapy. For example, if someone has arachnophobia, they would be exposed to spiders to overcome their fear. However, exposing a patient to complex social interactions can be challenging.
Newman often role-plays with her patients, playing out scenes such as public speaking or large parties that may cause anxiety. Sometimes she brings in other therapists so the patient can truly interact with a new person, making the exercise seem more real. But it’s never a perfect replication of an anxiety-inducing situation for a patient with SAD.
When a virtual reality start-up company from southern California named Limbix, which recently sold its VR department to BehaVR, approached Newman about collaborating to develop a VR-based therapeutic, she suggested that they create one to help people with SAD.
“This is basically a digital form of exposure therapy,” said Aaron Gani, founder and CEO of BehaVR. “When we do it in VR, we can create these multisensory simulations that deliberately arouse you while you practice these skills. That can be really, really helpful when we want to deliberately trigger your arousal of your threat processing or your fear.”
BehaVR hired actors to play out scripted scenes that someone with SAD may find anxiety-inducing like parties, interviews, and public speaking. The player can interact with these actors in a virtual world. Interactions with the actors are not dynamic. Like a chat bot, the actors have standard responses based on the situation. But as the technology develops, Newman hopes the actors can become “smarter,” responding differently based on what an individual says.
A key aspect to the VR experience is that it’s self-guided; a therapist doesn’t need to be present for the patient to play through the scenarios. A therapist acts as an omniscient narrator, walking the player through the scene and advising them on how best to respond or handle the situations they encounter. As they progress through the virtual scenarios, the tasks they must complete get more challenging.
In one scene, the player is at a party and the therapist directs them to greet the host. After they greet the host, the host offers to get them a drink from the bar. But the host gets them the wrong drink. The therapist encourages the participant to be assertive and tell the host they got them the wrong drink.
“There is some data that generally people do find having to be assertive or some kind of public speaking situation more challenging than interacting with one person,” said Newman. “[In the scenarios], you have to be assertive. You have to ask for directions to the bathroom. You have to talk to a person in authority. There’s a public speaking scene where you have to talk for five minutes about something to the whole group.”
In her small clinical trial testing the efficacy of these experiences amongst forty undergraduate students, she found that participants’ SAD symptoms were less severe three and six months after starting the virtual therapy based on self-reported questionnaires (5).
BehaVR continues to build on Newman’s VR experience developed in collaboration with Limbix. Now, the game has a virtual guide named Ari, an artificial intelligence (AI) driven assistant that teaches players about cognitive reframing.
Cognitive reframing is a process where someone learns to recognize how they may respond to or interpret a situation in a way that negatively affects them and then reframe it. One example of a negative thought pattern is catastrophic thinking. Someone may think, “It’s too hard to speak in front of people. I’ll never be able to do this.” With reframing, someone may think, “Speaking in front of people is hard, but I can do it.”
Ari asks players to select unhelpful thoughts they may experience, categorize them, and find a way to reframe the thought. This part of the game is designed more like a classical video game with a computer-generated imagery (CGI) based environment. The player walks through the “Woods of Wisdom,” where they interact with the environment to learn about proven therapeutic strategies for overcoming their fears in an engaging way.
“If it’s just talk therapy, the therapist may say, ‘Let’s think about evidence that supports that thought and evidence against that.’ In VR, you’re walking through this action module where you’re literally gathering evidence. You’re pulling fruit off a tree and holding it to your mouth. You’re speaking evidence for and against it. You’re weighing the evidence on a scale. It’s a whole involved process,” said Gani.
Gani added, “We're creating gamified digital self-service experiences that are translations of evidence-based cognitive behavioral therapy techniques. That goes back to our mission to increase access. There are not enough therapists to go around. We're trying to make this stuff really, really engaging and really accessible to lots of people.”
In the field
Rizzo also uses VR to develop a type of gamified exposure therapy for veterans with PTSD. Exposing someone to the same setting they experienced during combat may seem counterintuitive, but some veterans claim that playing commercial first-person shooter games such as Call of Duty help them cope (6). The concept isn’t baseless. Prolonged exposure therapy is a therapeutic strategy used to treat PTSD. It involves reliving a traumatic memory through retelling, and then slowly exposing and processing triggers — places, people, and sounds — in real life.
“With the evidence base that already existed in the real world of traditional therapy, our vision was to use virtual reality to deliver for our clients immersive experiences that can be customized to what they went through. And [we aim] to put them within these virtual experiences in a way that helps them to confront and reprocess the difficult emotional memories that they went through, to not avoid these things, to dig in a bit, but in the safety of a supportive clinician’s office, of course, while this is not self-help treatment,” said Rizzo.
“In combat, we use the best technology to pursue wars, why not use the best technology to fix the problem after the fact when the problem arises?” Rizzo added.
Rizzo’s VR experience, dubbed BraveMind, includes fourteen different immersive scenes that can be customized to best match an individual’s traumatic memory. The participant may find themselves in a bustling marketplace, a small village in Afghanistan, or an open roadway in the desert.
Before the veteran ever puts on the VR headset, they have several meetings with their therapist to build trust and begin the first step of prolonged exposure therapy, retelling the traumatic memory related to their PTSD. This information also helps the provider determine what scene suits the veteran and begin modifying from there. The patient next describes the traumatic event with the VR headset on as the therapist adjusts the scene to match what they describe, completely immersing them in the memory.
Rizzo clarified that there is no gore in the experience or simulated gun firing. This is not a game, but a therapeutic tool meant to help patients better engage with and access treatment.
Making these VR experiences accessible is important to Rizzo. He teamed up with a foundation called Soldier Strong to develop a program that distributes free equipment — VR headsets — and training to clinicians at any VA medical center that wants it.
“I'm excited about the future of this work because I think everybody had exposure to trauma at some point in their life. A lot of us can dust ourselves off and move forward. A lot of people aren't that lucky for whatever reason, their history or their nervous system, the way it's wired. They have enduring impact from that trauma that limits them as they move forward in life, saps their joy, and we want to change that,” said Rizzo.
Entering the mind
Nanea Reeves, CEO and co-founder of the VR meditation company TRIPP, also wants to help others find joy through meditations in a virtual setting. Reeves worked in the video game industry for decades, holding positions at industry leaders like EA Games, Sony, and Oculus. When her husband died from cancer in 2015, Reeves revisited a coping technique she learned as a teenager: meditation.
She decided to combine her expertise in video game development and passion for meditation to “use technology to make people feel better and hack their states of consciousness.” She founded TRIPP in 2017. TRIPP is a mobile app that works with VR headsets like the Oculus Quest to immerse the user in trippy scenes overlayed with guided meditations.
“In virtual reality, a lot of people spend time kind of simulating the real world. That wasn't our goal. We're not interested in sticking you on a beach and having someone’s voice walk you through inhaling and exhaling. That wasn't really our approach at all. We thought, why not give people a transformative experience that can be triggered through an innovative environment that you can't experience in the real world?” said Reeves.
Rather than tell the user to inhale and exhale, the game simply helps players visualize their breath, showing light coming out of the mouth and particles moving back in. They may feel like they’re floating through space even if they are sitting on a couch with a dog curled up on their laps.
People can even design their own environments. Reeves said that she has seen people who are sick upload an idealized, healthy version of themselves to remind them their identity is not their illness. She’s also seen users “create weird psychedelic vision boards where they're setting intention.”
But there’s more to TRIPP than vision boards. The company is conducting several clinical trials to test the effectiveness of their VR experiences for improving mental health. One trial tests if TRIPP can help people recover from addiction.
“We don't make any claims. Now we're not a replacement for treating mental health or seeking professional help. We see ourselves more as a tool,” said Reeves.
But Reeves is encouraged by the power of her tool based on a recent study conducted in collaboration with the National Mental Health Innovation Center at the University of Colorado. The pilot study took place at a residential treatment center. The participants used TRIPP during the first 28 days of their treatment as a mindfulness exercise. The preliminary results showed a direct relationship between the frequency of using TRIPP and reductions in cravings. Reeves is encouraged, but clear that more data is needed.
She is also collaborating with another company, Sober Grid, a “mobile sober community,” to see how VR based meditation can help substance use disorder patients prevent relapse. They recently completed a phase I pilot study and are starting a phase II trial. In the trial, they introduce patients to TRIPP while they are still in treatment. Once they graduate, they receive a VR headset and are onboarded with the Sober Grid community. The researchers follow the patients for six weeks to see if the combined influence of a community and mindful mediation can reduce relapse rates.
“It's very exciting, this whole area of software as a medical device, or this category of digital therapeutics,” said Reeves. “I think it’s going to be a huge contribution to society.”
- Anguera, J.A. et al. Video game training enhances cognitive control in older adults. Nature 501, 97-101 (2013).
- Anguera, J.A. et al. Long-term maintenance of multitasking abilities following video game training in older adults. Neurobiol Aging 103, 22-30 (2021).
- Li, G. et al. Enhanced Attention Using Head-mounted Virtual Reality. J Cogn Neurosci 32, 1438-1454 (2020).
- Wais, P.E., et al. Virtual reality video game improves high-fidelity memory in older adults. Sci Rep 11, 2552 (2021).
- Zainal, N.H. et al. Pilot randomized trial of self-guided virtual reality exposure therapy for social anxiety disorder. Behav Res Ther 147, 103984 (2021).
- Colder Carras, M. et al. Connection, meaning, and distraction: A qualitative study of video game play and mental health recovery in veterans treated for mental and/or behavioral health problems. Social Science and Medicine 216, 124-132 (2018).