NEWS FEATURE

NEWS FEATURE
Virtual reality therapy set for a real renaissance
As the technology becomes cheaper and more accessible, and as research on its
effectiveness matures, virtual reality is treating an array of vexing mental ailments.
M. Mitchell Waldrop, Science Writer

A war veteran fits a virtual-reality headset over his eyes Afghanistan can be the stuff of nightmares—literally.
then lowers a pair of noise-cancelling headphones This is Bravemind, a virtual reality (VR) system created
over his ears. After a moment of near-silent darkness, 14 years ago to help veterans confront and overcome
he finds himself bathed in harsh sunlight, standing on horrific experiences that left them with posttraumatic
a rocky outcrop in Afghanistan. He turns to the left and stress disorder (PTSD). More precisely, this is a version
right: there’s nothing in sight but barren hills. He glan- of Bravemind that’s been liberated from its original
ces up: a helicopter is passing over. The war seems hardware, a head-mounted display that cost $3,000,
distant. Suddenly, a fountain of rock and dirt erupts and ported to an $800 HTC Vive: one of a new gener-
down in the valley: a mortar round. A few seconds ation of lightweight, consumer-oriented VR headsets
pass, and another round hits farther up the hillside. originally developed to supercharge online gaming.
Then another. He watches helplessly as the explosions These new headsets are being hailed as potential
approach. Closer, until the world vanishes in a roar of game changers for VR-based mental health applica-
light and sound. . . . tions across the board. They have rebooted interest in
It is a heart-thumping experience for anyone. But older therapies that, like Bravemind, provide a uniquely
for veterans of the real thing, immersion in this virtual vivid and intense alternative to traditional talk-based

Fig. 1. First created 14 years ago, Bravemind, a virtual reality system for helping veterans confront horrific battlefield
experiences, has recently undergone upgrades that could greatly expand its reach. Image courtesy of University of
Southern California Institute for Creative Technologies.

www.pnas.org/cgi/doi/10.1073/pnas.1715133114 PNAS | September 26, 2017 | vol. 114 | no. 39 | 10295–10299

 therapies for PTSD and phobias. And the headsets are when he was attending a conference on computer
opening up experimental treatments for conditions, such graphics. Slater had heard of VR—the basic idea had
as pain and depression, that take advantage of the been around since the 1960s—but this was during the
unique properties of VR. first big surge of commercial interest in the technol-
“Virtual reality is now in a renaissance,” says Arno ogy, when enthusiasts were everywhere. “At first I was
Hartholt, a computer scientist at the University of disappointed,” he says. “I just saw fat pixels. But then
Southern California and the coprincipal investigator they said, ‘Move your head’—and suddenly, I was in a
on Bravemind. “And that’s good for us, because we’re different place. I heard music. I moved over to window
getting capabilities for therapy that are affordable.” and looked out. I saw a lady in a boat.” It was a career-
“I think there are very few mental health conditions changing moment, says Slater: “From then on, I be-
for which VR could not be useful,” says Daniel Free- came interested in how that worked.”
man, a clinical psychologist who studies VR treatments The answer turned out to be fairly obvious in ret-
for paranoia at the University of Oxford in the rospect, Slater says. If you turn your head, or stoop
United Kingdom. down, or walk forward, the headset simply should
Freeman acknowledges the challenges, though, detect that motion using built-in accelerometers or
from the programming of complex and individualized other position sensors and then shift the synthetic
therapeutic scenarios to continually proving that they images in a way that the computer calculates from
benefit patients. But based on the clinical successes to the 3D geometry of the scene. Because this is ex-
date, Freeman is “incredibly optimistic about what can actly the way your brain expects the images on your
be done.” Soon, he believes, VR technology could retina to shift as you move through the real world, it
provide the equivalent of the world’s best therapists interprets the scene as real. “The brain doesn’t like
in people’s living room. contradictions,” says Slater. “If you’re perceiving
the world the way you usually do, the brain assumes,
Tricking the Brain ‘Here I am.’
VR-based therapy exploits a psychological phenom- Although that early generation of VR equipment
enon known in the trade as “presence”—the illusion never made it far beyond laboratories and industry—
that you are really in an environment, not just looking you could have easily paid more than $200,000 for
at a picture of it. This isn’t simply a matter of hyper- graphics that were pathetic by today’s standards, says
realistic displays, says Mel Slater, a computer scientist Slater—it was good enough for at least some re-
at the University of Barcelona in Spain. He vividly re- searchers to start experimenting with mental health
members his first time trying on a headset in 1990, applications. Their field was full of therapies that

Fig. 2. Experiencing realistic virtual scenes of war has helped some veterans overcome severe PTSD. Image courtesy of
University of Southern California Institute for Creative Technologies.

10296 | www.pnas.org/cgi/doi/10.1073/pnas.1715133114 Waldrop

worked—eventually—but that were painfully slow, Virtual Vietnam for 90 minutes at a time, twice a week,
expensive, and cumbersome in practice. Could VR while he talked through his specific traumas and the
turn them into something much quicker, easier, and therapists adjusted the simulation details to get the
more powerful? closest match.
After two weeks, and again when they were
Safe Exposure retested six months later, the patients showed signif-
In Atlanta, psychologist Barbara Rothbaum at Emory icantly reduced PTSD symptoms. And that was espe-
University and computer scientist Larry Hodges at cially gratifying, says Rothbaum: “If they were still in
the Georgia Institute of Technology were among the system after so many years, they were pretty re-
the first to ask themselves that question. For de- sistant to standard treatments.”
cades, explains Rothbaum, by far the most effective In New York City, JoAnn Difede hit on much the
treatment for many anxiety disorders has been ex- same idea in the aftermath of the terrorist attacks on
posure therapy: encouraging someone with, say, a September 11, 2001. “The day after 9/11, I knew we
fear of heights to gradually walk closer to the railing would have a public health problem,” says Difede, a
of a balcony or to ride in a glass elevator. When psychologist at the Weill Cornell Medical College on
nothing bad happens, the fear begins to diminish. the Upper East Side of Manhattan.
But most psychiatrists don’t like doing it, Rothbaum By October 2001, she was collaborating with Hunter
says, because it’s difficult to find suitable locations Hoffman, a computer scientist at the University of
and take all those trips out of the office. So in 1993, Washington, on a virtual replica of the streetscapes
she and Hodges started asking whether exposing around the World Trade Center. “We used a
patients to heights via VR could be therapeutic
without the hassle.
It was: in 1995, in a pilot study that was the first “Running past this one spot brought back the memory
published account of VR used to treat any kind of
and allowed her to process it.”
psychiatric disorder, the team showed that 7 of the
10 people who received the treatment then went out —JoAnn Difede
and voluntarily subjected themselves to real high
places—a success rate similar to non–VR-based ex-
posure therapy (1). $25,000 head-mounted display that weighed 10 pounds,”
Next, the group tackled a condition that’s even she says. “Dell donated a workstation; consumer tech-
more cumbersome to treat with exposure: fear of fly- nology couldn’t hack it.”
ing. “If you do it in the real world,” says Rothbaum, “it One of the first patients to use the system was a
means taking patients to the airport, getting them on young woman who had had to run for her life as the
board—it’s expensive and time-consuming. And in- twin towers collapsed behind her (4). Once an upbeat,
surance won’t pay for me to fly with them.” She and deeply religious person, she had become moody and
her colleagues showed that sessions inside a virtual irritable, yet numb and flat.
airliner cabin crammed with avatars representing real “But as soon as she put the headset on,” says
people could alleviate fear just as effectively as ex- Difede, “she went ‘Oh my God! I never thought I’d see
posure in the real world (2). It also had some key the World Trade Center again!’” By the second ses-
practical advantages. “With VR, they could take off sion, the patient was reliving how she had fled the
and land many times in a 45-minute session,” says catastrophe. After several sessions, she remembered
Rothbaum, not just once. “And if I thought the patient something she had repressed: a woman had begged
wasn’t ready for turbulence, there would be no her for help—yet she had run past without stopping.
turbulence.” There was nothing she could do for the woman, whose
That success gave the team enough confidence to legs had been severed by falling debris. But the mo-
take on combat-related PTSD, which can leave its ment left Difede’s patient with crushing guilt.
victims vulnerable to recurring nightmares, un- “Running past this one spot brought back the
controlled rage, alcohol and drug abuse, suicidal memory and allowed her to process it,” says Difede.
thoughts, and more. Because exposure therapy in a And after that, the young woman’s symptoms im-
combat environment is impractical, the gold stan- proved markedly. “That example was powerful for
dard has been a variation known as “imaginal” ther- me,” says Difede. “This was an experiment, and we
apy: asking the veteran to recall traumatic events had no idea if it would work.”
maybe a dozen times per session or more. But not ev-
eryone has a vivid enough imagination—or wants Trauma Meets Gaming
to remember. Difede, Rothbaum, and many other researchers were
So the team’s idea was to use VR to as a kind of soon invited to collaborate on the Bravemind project,
booster for imaginal therapy, making the re- which was initiated by University of Southern California
membered scenes vivid and tangible. For their pilot psychologist Skip Rizzo in 2003. Because Bravemind
study published in 2001, they recruited 10 male had Pentagon backing—Rizzo and his team adapted
Vietnam veterans still suffering from PTSD more than the first version from Full Spectrum Warrior, a video
two decades after the war ended in 1975 (3). Each of game they had originally developed to train small-unit
the veterans then experienced the researchers’ commanders—it quickly became the most sophisticated

Waldrop PNAS | September 26, 2017 | vol. 114 | no. 39 | 10297

 headsets, and expanding its scope. Since 2014, for
Feeling Real
example, they have been adding content to help
The psychological phenomenon known as “embodiment” takes the illu- people cope with military sexual trauma. The VR sys-
sion of presence in the virtual environment a step further: not only do your tem doesn’t attempt to show the actual assault, he
surroundings feel real, but your avatar body feels like it’s your own. And says, but instead emphasizes the context that leads up
that opens a door to using VR to give people who need it a new per- to it—the sound of a lock turning, say, or the sight of
spective on “self.” an assailant standing in a doorway blocking any es-
“It’s pretty straightforward,” says Mel Slater, a computer scientist at the cape. Results from a Veterans Administration clini-
University of Barcelona in Spain. “Your whole life, you look down and you cal trial of that application, currently underway, are
see yourself, you look in a mirror and you see yourself. Well, in VR you have expected in a year or two.
the headset and motion tracking, so you can do the same.”
The correspondence doesn’t have to be exact, notes Slater’s Barcelona VR Therapies in the Real World
colleague, Maria Sanchez-Vives; the brain is remarkably good at filling in The new wave of consumer headsets, which rely on
missing sensations like touch, smell, and even sound. But the sensations you the high-resolution displays being mass-produced for
do receive have to be consistent, she says: “If you sit in a chair, your virtual smartphones, started with the announcement of the
body should sit in a chair.” Oculus Rift in 2012. It hasn’t taken long for researchers
Interestingly, says Sanchez-Vives, the sense of embodiment doesn’t seem to recognize the potential for bringing existing ther-
to be affected by differences in race, gender, or age. “In one of our first apies to a wider range of patients as well as for de-
papers on the full body illusion, we put adults in the body of a little girl,” she veloping new treatment approaches that can really
says (9). “And we’ve done several experiments with racial bias—giving sub- only work with VR. “Now that the technology is in-
jects a virtual body with a different race. Nobody has expressed any kind of expensive and portable, applications are limitless,”
incongruence.” That conclusion is borne out by objective tests, such as says Difede.
showing that people’s real heart rate shifts into fright mode when their virtual Since 1999, for example, Difede’s colleague Hoffman
body is threatened with harm. and University of Washington psychologist David
But wearing a different body does have profound psychological ef- Patterson have been developing SnowWorld (6), an
fects, says Slater. When adults are given a child’s body, for example, they immersive VR environment for pain control in people
start to label themselves with childlike attributes in word association tests with severe burns.
and to overestimate the size of objects in exactly the way real children do. Rather than pain-killing drugs, which can be dan-
And when white people are embedded in a black body, says Slater, they gerous, SnowWorld offers a particularly vivid form of
start to show marked decreases in measures of implicit racial bias—an distraction. During their excruciating daily regimen of
effect that lasts at least a week after exposure (10). wound-cleaning and dressing-changes, patients don
With further development, says Sanchez-Vives, this could make VR a the headset and spend the time drifting through a
powerful training tool for increasing interpersonal compassion. And in the kind of glacial canyon, launching snowballs at snow-
meantime, she says, the sense of embodiment could be used to treat a men and penguins that pop up at random along the
wide variety of pathologies that affect body awareness, from the loss of a walls. It’s quite cartoonish—yet engrossing enough to
limb to anorexia. block out the agony, turning pain into little more than
an annoyance.
Now, Hoffman and his colleagues are finally able
VR exposure treatment ever. And the most widely to port SnowWorld into new-generation headsets
deployed: it’s currently running in more than 60 Vet- that are light and cheap enough for routine clinical
erans Administration hospitals, military bases, and re- use. And along with Difede, Hoffman is also starting to
search labs, facilitating therapies that closely conform experiment with VR-based pain relief in other situations,
to patients’ memories. “The clinician can set all kinds of such as chemotherapy and presurgical procedures.
parameters,” says Hartholt, who became the project’s One of the research frontiers for VR therapy is to
coprincipal investigator in 2008. “Afghanistan or Iraq, make use of an extension of presence known as
riding or walking, urban or rural, day or night.” “embodiment,” in which users feel that the virtual
In 2010, a small study using fMRI brain scans found body they glimpse in the simulation is literally their
this kind of VR exposure therapy to be at least as ef- own (see sidebar). A particularly promising application
fective as imaginal therapy at damping down the hy- of this phenomenon is to calm the relentless self-
peractivity typically seen in a PTSD patient’s amygdala criticism that’s so common in conditions such as de-
and hippocampus—the first being the seat of the fight pression—perhaps the leading cause of disability
or flight response, and the second, a key site in worldwide (7). “People may feel that they don’t de-
memory formation and presumably the source of serve to be treated kindly,” explains Christopher
haunting flashbacks. Both therapies also seemed to Brewin, a psychologist at University College London.
restore normal activity in frontal-lobe areas that are In 2016, he, Slater, and a team of other psycholo-
inhibited in PTSD and may account for the disorder’s gists published an encouraging pilot study of a VR-
characteristic emotional numbing and social with- based treatment (8). Fifteen subjects diagnosed with
drawal (5). A much larger comparison with some depression wore a headset that gave them the form of
200 patients is now underway. an adult avatar and were asked to comfort a distressed
In the meantime, says Hartholt, Bravemind’s de- virtual child. The system recorded their voices as they
velopers have focused on upgrading the underlying did so. Then the subjects were taken through the
game technology, including the port to new-generation scenario again from the perspective of the child. In

10298 | www.pnas.org/cgi/doi/10.1073/pnas.1715133114 Waldrop

that guise, they listened to the adult avatar speaking Freeman works closely with psychologists and pro-
their own compassionate words and gestures. After grammers to put virtual coaches in the scene who
repeating this cycle once per week for 3 weeks, all the “guide you through the situations that trouble you, ask
subjects showed measurable decreases in depression you questions, give you feedback and advice, and
and self-criticism: somehow, their self-perceptions
personalize your treatment.” That takes a lot of pro-
changed when they saw themselves from the out-
gramming effort, says Freeman, because this kind of
side as a caring person.
The team is currently looking for funding to do a therapy is anything but one-size-fits-all: “You have to
much larger study that will nail down the clinical take each condition on its own, know about its various
benefit, says Brewin—and, not incidentally, to port the manifestations, and then tailor the treatments within
software from their original, $65,000 lab setup into the algorithm.”
consumer-level equipment. “So instead of special labs Still, Freeman says, if this kind of automation can
where people have to come to,” he says, “we can be made to work, it would open up the possibility of
imagine people downloading things into their own instant access to therapy, without an appointment or
headset in their bedroom.” prescription. “Traditionally in mental health, your choices
for treatment have been taking medication, or talking
Virtual Therapists?
with therapist,” says Freeman. “But for me, what’s really
At Oxford, Freeman and his team are working to make
important is what happens outside, in the situations that
that vision a reality for far more people. “The issue is
that it has so far been used in clinics, with therapists people find difficult. And the best treatment happens
there,” says Freeman. But because good therapists when you can practice right there, in the moment.”
are in short supply, he says, researchers need to au- That’s where virtual reality shines, Freeman says:
tomate that kind of feedback so that people can have “It’s like having a personal trainer, a coach, right there
access to it at home. with you.”

1 Rothbaum BO, et al. (1995) Effectiveness of computer-generated (virtual reality) graded exposure in the treatment of acrophobia. Am
J Psychiatry 152:626–628.
2 Rothbaum BO, Hodges L, Smith S, Lee JH, Price L (2000) A controlled study of virtual reality exposure therapy for the fear of flying.
J Consult Clin Psychol 68:1020–1026.
3 Rothbaum BO, Hodges LF, Ready D, Graap K, Alarcon RD (2001) Virtual reality exposure therapy for Vietnam veterans with
posttraumatic stress disorder. J Clin Psychiatry 62:617–622.
4 Difede J, Hoffman HG (2002) Virtual reality exposure therapy for World Trade Center post-traumatic stress disorder: A case report.
Cyberpsychol Behav 5:529–535.
5 Roy MJ, et al. (2010) Improvement in cerebral function with treatment of posttraumatic stress disorder. Ann N Y Acad Sci
1208:142–149.
6 Hoffman HG, Patterson DR, Carrougher GJ (2000) Use of virtual reality for adjunctive treatment of adult burn pain during physical
therapy: A controlled study. Clin J Pain 16:244–250.
7 WHO (2017) Depression. Available at www.who.int/mediacentre/factsheets/fs369/en/. Accessed May 23, 2017.
8 Falconer CJ, et al. (2016) Embodying self-compassion within virtual reality and its effects on patients with depression. BJPsych Open
2:74–80.
9 Slater M, Spanlang B, Sanchez-Vives MV, Blanke O (2010) First person experience of body transfer in virtual reality. PLoS One
5:e10564.
10 Maister L, Slater M, Sanchez-Vives MV, Tsakiris M (2015) Changing bodies changes minds: Owning another body affects social
cognition. Trends Cogn Sci 19:6–12.

Waldrop PNAS | September 26, 2017 | vol. 114 | no. 39 | 10299