In 1966, ELIZA (1) was unveiled as a virtual therapist with which a computer user and a computer could engage in a nondirective “psychotherapy session” in a text-based conversation. Although it was never used as an actual treatment tool, a seed was planted: computers and computer simulation could become important tools in the treatment and diagnosis of mental illness.

Broadly defined, computer simulation allows human users to interact with digital environments resembling reality. Many are familiar with virtual reality, a form of computer simulation, from gaming and entertainment. Virtual “worlds” such as those used in Second Life (2) and the multiplayer online role playing game World of Warcraft (3) boast millions of users worldwide. Unlike simple web pages, these rich environments use computer simulation to create a moderately faithful representation of the real world in which players and users can interact with computers and one another.

Within medicine, computer simulation is increasingly seen as an important teaching tool and therapeutic modality. Virtual reality has found wide application in such varied tasks as helping surgeons develop surgical skills (4–6) and the use of artificial intelligence to mimic human communication (7).

This article highlights uses of virtual reality for the treatment of mental illness, specifically exposure-based therapy, support groups, social skills training, patient education, personal health coaching, and assessment of functional ability.

Exposure therapy has long been a component of treating several psychiatric disorders, including social phobia, specific phobia, and posttraumatic stress disorder (PTSD) (8). Exposure-based treatment is widely used in cognitive behavior therapy (CBT). Exposure treatment involves repeatedly presenting a patient with anxiety-producing stimuli with the goal of desensitizing a patient’s anxious response.

Specific Phobias

Virtual reality exposure therapy has been used to treat panic disorder, social phobia, fear of flying, fear of heights, and arachnophobia. During these exposures, a patient will typically wear virtual reality goggles, which will display realistic images of the feared stimuli. The therapist is able to titrate the intensity of the stimulus for optimal therapeutic anxiety—the level of anxiety needed for desensitization without overwhelming the patient. In a simulation used for the treatment of social phobia, the patient must read a speech in front of a virtual audience. Prior to the simulation, a therapist creates a fear-hierarchy consisting of increasingly anxiety-provoking simulations tailored to each patient. During this simulation, the patient wears a head-mounted display that presents a computer-generated lecture hall or conference room. The therapist can control the number of virtual audience members listening to the patient’s speech and the audience members’ reactions to the speech. Audience members look interested, bored, or even walk out during the speech (9).

Virtual reality also has the capacity to expose the patient to the different parts of an experience that may surround a specific phobia. In exposure treatment for fear of flying, the patient walks through the airport, waits for a boarding call, enters the plane, and sits through the take-off, cruising, and landing portions of the flight (10–12). Therapists optimize the amount of anxiety a patient experiences by controlling the intensity of the experience by selecting smooth, turbulent, or stormy flight conditions.

Similar virtual reality exposures have been developed for arachnophobia, fear of heights, and agoraphobia. A recent meta-analysis (13) of 397 subjects in 13 studies of virtual reality exposure therapy for a broad number of anxiety disorders showed a large mean effect size (Cohen’s d=1.11) for virtual reality exposure therapy compared with control conditions (waitlist, attention control, bibliotherapy, or relaxation). In vivo exposure therapy was not more effective than virtual reality exposure therapy.

PTSD

Virtual reality is a promising tool in treating combat-associated PTSD. In the Virtual Iraq study (14, 15), participants are presented with combat-related scenarios that include visual reproductions of desert combat accompanied by 3D directional audio, vibrotactile, and olfactory stimuli. In recreating the conditions in which the patient was initially traumatized within this virtual environment, reduction in PTSD symptoms is thought to result from habituation to the anxiety-provoking stimuli. Pilot data suggest that the simulation was helpful in reducing PTSD symptoms in six of eight participants after seven sessions. The study has been extended to over a dozen medical centers in the United States.

Substance Abuse

Virtual reality may be useful in the treatment of substance use disorders. Bordnick and colleagues (16) noted an increase in alcohol cravings when they exposed 40 nontreatment-seeking drinkers with alcohol use disorders to alcohol-related cues. Cravings increased when participants were exposed to a virtual bar scene, a party, and a kitchen that contained alcohol. Cravings did not increase when participants were exposed to neutral stimuli. The authors suggest that this virtual environment may be a useful modality though which patients can practice alcohol avoidance strategies. Similar increases in nicotine cravings have been noted in nicotine-dependent participants exposed to smoking-related cues in a virtual reality environment (17).

Virtual worlds allow patients to connect with one another and therapists for support and skills acquisition.

Support Groups

Second Life (2) is an online, 3D virtual world with over 6 million members, who navigate through the use of “avatars” (humanoid representations of themselves). Among the almost limitless number of activities that exist within Second Life, members can play games, buy and sell virtual goods, socialize with other members, date, conduct research in interactive virtual libraries such as Healthinfo Island (18), or attend lectures such as those sponsored by the journal Nature.

Members socialize through keyboard-based typed text (similar to instant messaging) or voice chat. Avatars can perform a large number of behaviors—hand movement, gaze aversion, body posture, interpersonal distance, clapping, and more—to provide nonverbal cues (19).

Support groups for several psychiatric illnesses exist where members can support one another and exchange information, such as in peer-run support groups for anxiety, depression, and bipolar disorder (20).

Second Life is also being used as an environment in which patients learn to use certain treatment tools. For example, progressive muscle relaxation techniques are being taught to groups of patients by real-world therapists within Second Life (21).

Social Skills Training

Researchers at the University of Derby are studying Second Life as a tool for teaching social and communication skills to patients with autism spectrum disorders (20). By practicing social encounters with other people within the virtual space, the study authors provide a safe space in which patients can repair deficits in verbal and nonverbal communication.

Virtual simulation is also being used to treat social skills deficits associated with schizophrenia. In a Korean project (22), participants practice initiating, maintaining, and ending conversations with strangers. Avatars give feedback to the patient using both verbal and nonverbal cues, such as looking at one’s watch to let the patient know it is time to end the conversation.

Virtual reality tools are also being used to teach patients and the public about mental illness and to encourage patients’ adherence with treatment.

Psychosis Education

Yellowlees and colleagues (23) used Second Life to replicate the experience that patients with command auditory hallucinations may experience. Users walk through a virtual-reality hospital ward where they hear multiple, overlapping, critical voices and see a floor that appears to be falling away, a mirror that shows the user dying, and a gun that is highlighted with command auditory hallucinations telling the user to kill himself or herself. The project was built as a tool for public education. During the 2-month study phase, 836 people toured the virtual environment.

Personal Health Coach

Animated humanoid, computer-based characters use speech, eye gazes, hand gestures, facial expressions, and other nonverbal modalities to emulate the experience of human face-to-face conversation with their users (24). These virtual clinicians, technically called embodied conversational agents, are used to monitor, motivate, and teach patients about medical conditions and treatments.

Researchers at Northeastern University are investigating the use of avatars in completing daily check-ins with patients. During these conversational interactions, the embodied conversational agent assesses mood state, gathers information about medication adherence, reminds patients of upcoming appointments, and encourages patients to follow through on plans to exercise and take medications. Although these technologies are still in development, the data obtained by the virtual clinician will be relayed back to the real-world clinician or treatment team.

Virtual environments are being developed as adjuncts to traditional neuropsychological testing. In one application, the Virtual Reality Cognitive Performance Assessment Tool (VRCPAT) (25), participants in a virtual city complete several tasks designed to test attention, spatial ability, memory, executive functioning, and reasoning abilities. Initial pilot data from 40 participants suggests that data obtained from 15 minutes within this simulation are highly correlated with traditional 90-minute pencil-and-paper testing.

Researchers (26) curious about medication adherence in patients with schizophrenia examined the neurocognitive deficits associated with schizophrenia using a virtual reality apartment. In this performance-based instrument, patients were required to use a broad number of neurocognitive functions in a complex virtual environment to complete a medication administration task. In this study of 25 patients and 18 comparison subjects, patients with schizophrenia demonstrated significantly more quantitative errors in dispensing medication and took medications late more often than comparison subjects.

A similar virtual environment has been constructed to study attention-deficit/hyperactivity disorder (ADHD) in children (27). Ten boys with ADHD and 10 comparison subjects were studied using a virtual classroom simulation. Wearing virtual reality goggles, participants sat in a virtual classroom filled with desks, a teacher, and other students and completed a go/no-go task. To more effectively simulate a realistic classroom environment, examiners had the ability to introduce distractions, such as paper airplanes, a car rumbling outside the virtual classroom window, and increased ambient classroom noise. Results suggested that this virtual classroom allowed for effective discrimination between participants with and without ADHD.

Virtual reality is a powerful tool in the treatment and diagnosis of mental illness. However, at this stage in development, many of the tools noted are not yet available to clinicians. As researchers determine the most effective way to use them, we can expect to see increasingly broad and innovative applications. For the most part, computer simulation is an enhancement to traditional therapy, not a replacement. The therapist has an interactive role in treatment, such as acting as a coach in virtual reality exposure therapy and as a participant in virtual world groups.

Within computer simulation research, there is little discussion as to why virtual reality may indeed be so useful. The answer may be found, at least in part, in an examination of psychoanalytic theory. Virtual reality may represent the extension of classic object relations theory, as based on the concepts of Melanie Klein (28). In this theory, human beings relate to one another through the intermediation of their mental images; that is, they relate by means of proxy transactions using representations of self and other as defined by Otto Kernberg (29, 30). If we replace self-representation with avatar in this theory, the nature of virtual relationships is exposed.

For example, imagine Jack and Jill are negotiating a psychological transaction in a nonvirtual relationship: Jack has a mental image of himself and one of Jill. She has a mental image of Jack that is not identical with Jack’s self-image, and her own self-image is not identical with Jack’s representation of her. What is happening in the exchange is not direct but (according to object relations concepts) done by proxy for each party. In this analogy of a two-person relationship, there are four self-representations (i.e., “avatars”) interacting: Jack’s vision of Jill, Jack’s vision of himself, Jill’s vision of Jack, and Jill’s vision of herself. When these two individuals interact in Second Life, for example, their two avatars are analogous to the self and object representation of each of the two individuals. Each avatar is perceived as having certain desires and beliefs—and from these representational elements the infinity of transactions that characterize humankind are constructed. The avatar and the interaction may give the patient and therapist insights that may not surface in simply discussing a personal situation.

Although we are not proposing that psychotherapy be conducted in the virtual world, there is an uncanny similarity between aspects of object relations theory and interactions in virtual reality. It is as yet unclear just what features of real-life psychotherapy would generalize to a simulated relationship if a patient and physician were to interact in a virtual world—nor is it clear what experiences of “psychotherapy” in the virtual space could teach about psychodynamic process. Several questions arise: How are real-life interactions like the virtual world? What can we bring back from virtual to “real” reality? Could iterated mappings of generations of game play or simulated treatments in virtual reality supplement the huge body of case examples collected during a century of psychoanalytic literature? Especially intriguing is the issue of transference in virtual reality: will it be diminished by certain situations and environments or enhanced and magnified?

Didactic and training possibilities are only starting to be envisioned. Computer simulation allows a resident or trainee to play the role of virtual psychiatrist with standardized virtual patients—allowing for objective assessment, low-risk experimentation with technique, and easy review of the virtual case by supervisors. The possibilities are enormous and as yet mostly unimagined.

At the time of submission, the authors declared no competing interests.