Amy Barrett: What different types of therapies are there currently on offer?
Daniel Freeman: There are some fantastic therapies, a number of them developed in the U.K., particularly cognitive behavioural therapy (CBT) which has excellent evidence for treating problems such as anxiety and depression and forms of it, also used for conditions such as schizophrenia. So there’s a number of really good psychological talking therapies for a number of mental health conditions.
But the issue tends to be with getting them to enough people.
AB: Why is that a challenge?
DF: Well, I think there’s been a sort of fantastic recognition over the last few years that many, many people will have mental health problems. In any one year, about one in four people may have a mental health problem.
So this is a very large number. And actually there aren’t so many therapists skilled in the most effective treatment. So if you go to the right centre, see the right therapist, doing the right treatment, outcomes can be really good. But I think we’re moving for this recognition that there are a lot of mental health problems. But what do we do next? How do we get these really good psychological therapies to more people?
AB: In addition to talking therapies, what other kind of therapy is on offer?
DF: Yes, so what typically with mental problems, people are either treated with medication or psychological therapy or a combination of the two of them. The main sort of evidence-based treatments tend to be cognitive behaviour therapy. But there are other therapies, too. I think what’s very good, in the NHS, is that there’s a focus on using the therapies that have been shown to work in clinical trials that have got evidence behind them. And the best therapies tend to have a very clear idea about what causes the problem, then use that knowledge to develop really good therapeutic techniques, and then show that in clinical trials.
I think across some of the most effective therapies is going outside, into the situations that trouble people and really making new learning in those situations. So a bit more like sort of almost like having a personal trainer or a coach next to you. It’s helping a person work through some of the problems in the situations that trouble them often. That really tends to bring about a lot of change.
AB: And that’s where virtual reality (VR) therapy comes in?
DF: Well, exactly, because VR is immersing you in situations. One of the most powerful ingredients in therapy is about going out there and trying things in the situations that trouble you. In VR you can present those situations in a clinical room and you can present them in novel and in different ways. And what’s really exciting is that because the person knows it’s a stimulation, that it is not real, it gives them the psychological freedom to try thinking of behaving any differently. So it’s actually wonderfully therapeutic. It doesn’t break the spell knowing it is VR. it actually really helps people give a bit of flexibility in their thinking to try things anew. So we’re finding it is remarkably powerful.
AB: That’s surprising, as you might think that knowing it’s a simulation would make you less likely to feel confident it’ll help in a real-word scenario.
DF: Yeah, I think that’s probably the issue that people bring up the most to me, you know, it’s not the real world. So is it going to apply to everyday situations?
We’ve got lots of evidence that it transfers. Increasingly, the way I view it is that while you’re in VR for the overwhelming majority of your brain is the real world, your senses, your main senses, your vision and your hearing are all replaced by the digital simulation.
So that’s what your brain is processing. You are there. And of course, you know, I’ve seen it first hand where you only practise something in in a simulation with someone. And it does then immediately after, when you go into real world situations with someone, transfer.
Really, a sort of similar situation where people are even more convinced, is if you’re training to be a pilot and you’re doing simulations. People understand that works. And I think VR is the same in that way.
AB: CBT is commonly used for depression and anxiety. Are those the conditions that VR is best used for?
DF: No, I think for pretty much most mental health conditions, there is a potential for VR to be used. The evidence or where it’s been used, at least at the beginning, has been anxiety disorder.
So we know it works really well for that, but there’s no reason it can’t work for other conditions. We just need it to be tested and shown to work.
What I would highlight is that VR is not a solution in itself. You’ve got to develop the right content and you’ve got to test it. So just because it’s VR doesn’t mean it’s going to work. You have to have really smart content. You’ve got to have the content developed with people who have some of the difficulties, they influence the design. You’ve got the right theory. You’ve got to have the right treatment techniques. But if you get it right, potentially it can be used for pretty much most mental health conditions.
AB: Compared to, perhaps going to see one therapist, it sounds like it might be quite expensive to do?
DF: No. What we’ve been doing in Oxford is pioneering, automating delivery of psychological therapy in VR so that we think for some conditions one wouldn’t need a therapist. And for some you might just need more minimal contact. And then if you automate it, there’s the potential to get it to millions more people. And I think that’s the excitement.
We know, if you’ve got a good therapist doing the right therapy, outcomes could be great. But there are too few therapists. There are some great schemes in the UK to increase the number of therapies, and that’s great. We need more therapists. Improving access to psychological therapies in the UK is a brilliant change in the NHS to get many more therapists trained, many more people getting the best help. But we still need other ways too.
And I think VR could be a fantastic way of getting really good evidence-based therapies to many more people. It’s not it’s not the complete solution. We still need therapists. There are still complexities in mental health, but for certain things, I think it can really change it. And I think it’s coming. It will come in a number of years. It will be used. It works so well for the treatment, mental health problems. I think the question is just when’s it going to arrive?
AB: It’s hard to visualise what that therapy might be like. If I were someone that had anxiety and came to one of your studies to take part, what actually happens when I put the VR headset on?
DF: So, you would put the headset on and we have a virtual therapist coach called Nic. Nic has a Scottish accent and she’ll talk you through about how to use VR, then she’ll talk you through the understanding of the mental health problem, say it’s fear of heights or something. She’ll explain what causes fear of heights or what one needs do to overcome it. And then in our fear of heights programme she’ll take you to the atrium of a sort of very large shopping centre and she’ll say, you know, which floor do you want to start with? If you want to go to the first floor or the fifth floor and you get to choose which floor you want to go to, and that should take you up there. On each floor, there’ll be a task around fear of heights.
So in a fear of heights, people fear that something bad’s going to happen, that they’re going to fall off or throw themselves off or the building’s going to collapse. So there’s a whole range of tasks to bring a person right up to a height, not put up their usual defences, but to actually spend time around heights and learn that nothing bad is going to happen. And actually they’re going to be OK. So they form this new memory of safety.
The height might start off with you getting closer to the edge, but there’s a balcony there, and a then that’s sort of lowered. So you might then stand right there at edge, and then later on therapy, you’ll be going out on a on a sort of on a platform to rescue a cat from a tree. So you’re doing things you could never do in the real world, but in VR you can do it. So there is a playful element to see you make it a bit more fun, although it is terrifying if you have a fear of heights. But there’s a nice contrast. People are terrified, but there’s also a smile of delight where they’re rescuing this very mournful cat from the tree in the shopping centre. And that’s one of the things about VR – you can push the learning in ways you can’t in the real world so people can come on in leaps and bounds.
So then we typically do half an hour sessions. Fear of heights is around six sessions, something like that. At each session, you sort of, you know, progressively gets more difficult. So there are harder tasks to do. But in the end, what we’re trying to do is help people make new learning and get that to stick.
AB: You’ve seen patients actually using this. What is the most positive response you’ve seen?
DF: Oh, lots of positive responses, so, you know, in our fear of heights trial, the average reduction in fear of heights was 68 per cent. A large reduction with just two hours of therapy.
Fear of heights is an interesting one, often for people it’s easy to avoid it, apart from in work situations or family ones. So then afterwards, people say, well, I went with my children and went on, GoApe up in the trees, things they’d never have done before.
The work we’re doing with people with schizophrenia, we’re working people who find it very difficult, you know, just to go into the local shop or get on the bus to go to somewhere they want to do. And then, of course, if you can free them up of anxiety, where they don’t worry about doing these things, it opens up a lot of possibilities in life. So, anxiety really puts a weight on people’s shoulders, and when you can help people overcome that you can see the changes in people’s lives.
AB: What’s involved in planning and designing these simulations? How do you decide what you’re going to show?
DF: Yes, it’s a great question. We have a very in-depth design process, we’re very keen that we produce VR treatments that are least as good as the best face-to-face therapy, if not better. So we’re not interested in watered-down therapy.
So we involve a lot of people. We involve people who have had these sorts of difficulties. So we work with a wonderful mental health charity, the PIN Foundation, who help support us, bring in people who had the difficulties. So they’re involved in the design process.
We’ll have psychologists on my team there, we’ll have computer scientists there. We have experts in user interaction. So lots of people.
And what we might start off with is the is the target will have the basic psychological principles. But from then on, it is a huge fun part of the process designing and all these ideas that can come from everyone. You’ve got to align it with the right psychological principles. You’ve got to think about what this is achieving therapeutically. But then there’s a great interaction between lots of people suggesting stuff. And then sometimes the VR programmers will say, well, that’s that’s going to be far too difficult to do that. But other things they go, we could definitely do that.
And there are things we thought would be too difficult, they say, no, that’s OK. So it’s a really wonderful process. And often it you know, there’ll be a blank board at the beginning and the end will be filled with, you know, lots of ideas. And then we move to a sort of honing down, how you actually play this out in VR, in detail.
So we have storyboards, we’ll have a script, we’ll have all the timings for different things to happen. It’s a bit more like a movie at that point. And then there’s a whole bit about programming at once you’ve got the script all set up. So you’ll do recordings of people in motion capture. We animate our computer characters using recordings of real people’s movements. We obviously have actors for the sounds. There’s a lot of work for the environment artists and the computer programmers to put this in action. So it takes a lot of effort to do that. But of course, if you get this right, you’ve got a powerful treatment and then you’ve got a powerful treatment that can be scaled up. So I think, very much, it’s worth the investment getting it right.
AB: Why is virtual reality the best way to do this?
DF: Yeah, I don’t think it has to be VR. I mean, I think there’s probably stages. I like VR a lot because I think it shuts out the real world and immerses people in the world that we’re trying to use do the therapeutic work in. And so I think it helps get the person to really centre in that place. And I think that works.
But I think later on you could do augmented reality, you could blend it, you could move from VR into augmented. That makes a lot of sense too. And in other works we’ve done, we’ve just used a sort of mobile phone to provide reminders and things without even using any immersive elements too. So I think you could build up a whole range of different ways of doing it. Augmented I think it could be great.
But the first steps, I think certainly for people when they’ve got quite a strong problem, I think we’ve found the VR and just shutting out the rest and getting really immersed in that world has been really helpful. But I don’t think it’s the only way. There are obviously lots of ways that tech could be used in mental health, and I think we need to explore that. But of course, we always need to make sure that it works well, and that it’s what people want is the crucial thing, too.
AB: You’ve said the term ‘psychological process’. Can you explain what that is?
DF: Yes, so we’re very keen to to develop psychological treatments based upon the best psychological understanding of a condition. So, for example, that fear of heights example is talking about this idea that these these misinterpretations of heights, for example, there’s ideas that you’re going to if you’re going to throw yourself off. I does she want to it’s just what’s called the call of the void loss that he would have experienced, experience that kind of feeling or worse almost by standing by to try and sort of feel a bit like worrying about whether they’re going to sort of rush off. They don’t want to. But it’s it’s a fear and it’s a cognition. And we think that’s important.
We also think what actually happens is you’ve got this cognition of fear and you build up all these defences – so, you avoid going to new heights, for example, and therefore you never test out your fear. We don’t look at heights. And that way you think, well, I’ve only been saved because I put up my defences.
So I’ve just named two psychological processes. There’s there’s conditions there and there’s defences, what we call safety-seeking behaviours. So in a clinical trial, you can measure both of those processes throughout and then you can see whether change in those processes predicts change in the outcome, the overall fear of heights, for example. So there’s a nice way of building to trials and understanding of mechanisms.
AB: If we see that time in VR has a positive impact on our mental health, could it also be that spending time in VR – for gaming, for example – could have a negative impact?
DF: Well, I mean, I think I said anything, it’s always about the content, sameness or social media and things like that. There’s wonderful opportunities there, but there are also ways that it can cause difficulties. I think that’s the same with VR is like I said earlier, the tech itself is not necessarily the answer is all about the content.
So certainly mental health treatment, what you do is you want to show it works and also you pay attention to any sort of adverse effects or side effects, and one needs to keep that in mind. But yes, of course, with all things, there’s a potential for content that is that is unhelpful and can affect people’s mental health. But I think that that’s clearly possible.
AB: Are there any side effects you’ve found?
DF: No, we haven’t. So the one in involved that one particular attention to is motion sickness. So if you don’t depending on the type of kit and the sorts of things you get people to do in VR, you can get motion sickness.
And that’s not very nice. So we try and design stuff to make sure we’re not getting that. And that’s one of our design sort of elements we’re always paying attention to make sure we’re not using VR ways that could bring that on. Those sort of more basic versions of VR can bring these sorts of things on. And that’s not so nice.
So that’s probably the main one. But in a large trial, we’re going on the moon. We’re assessing a whole range of sort of more sort of minor ones really, as well about whether people are feeling any sort of sort of dissociation or other sorts of unpleasant feelings from being in VR. On the whole, we’re not picking up much of this at all, but it’s crucial that we measure it. So we’ve got a study in that current trial, a large assessment going through a whole range of detail.
So once that trial is over, we better look at these data to see. But on the whole, it seems it’s rare. So I started to work with VR, working with people with severe paranoia, and everyone was very worried that people would get paranoid about the kit, but we didn’t find that at all. We found if you explain what the kit is and its purpose to people with severe paranoia, they get it and actually rather enjoys getting access to sort of state of the art VR equipment.
So one has to pay attention to these sorts of concerns. One needs to make sure what measures are in trials. But actually, we’ve found a real sort of positivity around VR treatments that I’ve not seen for any other sort of treatment.
AB: Are there any precedents to a positive outcome? Any types of people, groups, that have better experience?
DF: Great question. That’s a question of clinical trials about moderation. Are there some factors that predicts the outcome?
We’ve not found in our studies to date, though, the studies have probably been too small to necessary to take that sort of subgroup. And certainly for fear of heights is very clear. It just pretty much works for everyone.
But in the larger trial, we’re dealing with patients with schizophrenia. I don’t think we’re necessarily expecting to find it. We’re expecting that it should work for most people to some extent, but we will know that when we’ve got the data in. So it is a good question.
Clearly, not everyone will respond if there are ways of understanding that that could then lead to enhancing and improving conditions.
So it’s a great thing to research. What one does is, says, ‘Well, it’s all very well. It works, but it is not working for everyone or it’s not working. It could work better for some people. Why is that?’ And one tends to both look at the clinical trial data, but also talk to people who’ve had the therapy to learn in depth about that as well.
So in the current Game Change trial, we’ve got the PIN Foundation carrying out interviews with some of the participants to really explore that level. And we can then triangulate that with the trial outcome results. So in all psychological therapy treatment, one is always wanted to do better. And one, therefore not only uses the sort of formal trial data, but as sort of more of a debrief with patients who’ve had it. So you can learn from that. I mean, it’s all obviously we’re all realising how important their areas. And there’s a real passion, I think, to improve treatment and to listen to people who’ve had these conditions to learn from that.
AB: You’ve mentioned a couple of conditions – depression, anxiety, but also paranoia and schizophrenia. Can you explain those a little more?
DF: Yeah, so my main area really in research, even before VR is about mistrust and it’s quite topical at the moment where we can see lots of distrust around the there’s a type of mistrust called paranoia, which is when you erroneously think artists are trying to harm you in some way, that they may be spreading rumours or they may physically harm you. And really, this is excessive mistrust.
So we’re interested in when people aren’t trying to do that to you because, of course, people can do bad things to paranoia is when you when you have the is unfounded ideas that people are trying to do that to you.
And there’s a whole spectrum of severity in the population. So some people have it mildly. Lots of people have these sorts of thoughts. And of course, that’s sensible because you have to decide whether to trust or mistrust. So this is this is perfectly normal sort of psychological processing. But sometimes people can get rather to skew to be mistrustful and sometimes that can be paranoia.
And when that becomes very severe in terms of you believe it very strongly and you get very distressed and impacts your life, it can be at the level of what we call a persecutory delusion. And that’s the most severe end of the paranoia spectrum. And that typically is considered a symptom of mental conditions such as schizophrenia. It’s not the only symptom, but it’s often quite a key one used in diagnosis. So paranoia is a particular type of mental health experience and it’s used sometimes it’s severe and to as part of the diagnosis of conditions within psychosis.
AB: How can VR therapy counteract that mistrust?
DF: Well, we’ve got great evidence that it can. So it is rather analogous to the fear of heights. What you’ve got is people who believe very strongly that when they’re around other people, that they’re going to do something bad to them. And therefore, typically they they avoid other people. They may avoid eye contact. If they’re out anda bout, they’re going to rush around. And so what we do in VR is enable people to drop these defences and find out what are what is going to happen when I’m around these computer characters.
Are they going to attack me and type out things so we get people to spend time around others in VR, we get them to make eye contact, get up close again, push things that you wouldn’t do in the real world, but to really learn it’s OK. And of course, the VR people are having these thoughts. They’re having the power thought just as they would about real people because VR triggers normal reactions. Yes they’ve got this conscious awareness. They know it’s a simulation. They can try things a bit differently and they could think, well, maybe these thoughts aren’t quite so accurate.
Maybe actually it’s okay. And then we get people to then do that in the real world. And in that way we build up these new memories. It’s all right to be around other people and we’ve got we’ve got some very nice initial data from a few years ago. And that’s led to much larger trials that we’re doing at the moment to try and to show that what we’ve seen a smaller scale level well, will generalise, which we’re pretty confident about.
AB: And how many people could this therapy potentially help?
DF: Great question. So in the game change, what we’re working on is there’s a people with schizophrenia, there’s an end result that many patients get too scared to leave the house for a number of reasons. It might be just they’re fearing negative judgement. For others, it might be paranoia. And about two thirds of patients with schizophrenia have these sorts of difficulties. And there are over 200000 people in England alone who have a diagnosis of schizophrenia. So this could help many NHS patients.
AB: How far away are we from actually offering this as a treatment?
DF: Well, it’s another very good question, so there’s different stages in treatment development, there’s a whole bit about developing a treatment and showing it works, and that’s why there are a lot of my work. But then there’s a whole area of getting something put into services and used, and that can be a major endeavour to what’s called the implementation. So, you know, you’ve got to provide it. You can have staff trained to use it, and that can take sometimes as long as the treatment development phase. But in Game Change, we’re trying to work very closely with implementation scientists who are doing a lot of studies about what are the barriers and facilitators to get these treatments into services.
So we’re already working very closely with NHS to try to get adoption as fast as we can. There is no real technical hurdles here, but there is a bit about getting these new treatments into services. I mean, I think the reality is it’s going to take a few years for this to happen.
It does take a lot to change systems sometimes, but I think there is a huge appetite for this kind of work.
AB: In your opinion, will it ever replace human therapists?
DF: My view really is we need more therapists. There are lots of instances where VR therapy is probably won’t be suitable. There are lots of instances where there’s a complexity there that you’re going to need a skilled professional involved.
But I think for many people, I think there is the possibility that they wouldn’t need to see a therapist and that they could do these sorts of things at home. I mean, fundamentally, you can view VR almost as an educational tool. And, you know, if you if you want to go and give a speech at work or something, then you could practise in VR. And, you know, it’s just as a sort of learning tool.
And, of course. If you’ve also got social anxiety, then you could do the same practise and it will be even more helpful and it will make you feel better about it. So there’s a nice blending between, you know, just making sure that you’re doing things as well as you can do. So I think many of us in the future probably will be using VR for lots of things, whether regardless of whether a mental health disorder or even have a mild version, you could just use this just to sort of top up how you’re performing. So I think there’s a really nice way to normalise mental health problems and the need to think about mental health and to try stuff.
So I said before, I think all of this will come in the future. It’s going to involve, you know, having the headsets at a price and ease of use, a quality. But I think that will happen.
AB: You’ve mentioned mistrust. Could VR therapy help with people who are mistrustful of taking a coronavirus vaccine?
DF: Well, I’ve certainly been doing research with the Oxford vaccine developers here about people who are hesitant about vaccines.
We’ve just been reporting on some work in the general population, looking at how many people are, for example, mistrustful of the COVID-19 vaccines, but also why identifying the sorts of beliefs that drive that and also some of the longer term drivers of mistrust. It’s you know, there are lots of reasons for it.
There are perhaps some ways the V.R. could be used.
We’re not at this stage yet of doing that. I think it’s a civilisation. I think at the moment we are very much focussed on how would you present information, accurate information strongly and well and what are the sorts of things that people need reassurance about So we’re at that stage really of thinking about vaccine hesitancy.
But of course, some people are just frightened of needles. So potentially one could do some things in VR with needles, for example. But there’s probably lots of other ways one could use fear potentially, although I think, of course, with just the sheer scale and timing of the endeavour ahead, we’re probably not going to be using VR for that at the moment.
But interesting idea. I hadn’t thought about that, but I should.
AB: All the work you’ve done over the years, what’s the biggest thing it’s taught you about mental health problems?
DF: So for me, I think it is two things really. It is that is that is the powerful learning that takes place when you can go out and practise something and within that enabling people to have the confidence to try things. And you have a new curiosity about things and to try things a bit differently.
So it’s kind of reinforced that key bit, in terms of change. It’s all very well talking about changes that one needs to make, but actually going in and practising it is crucial. And of course, talking about in a room can be hugely helpful part of the process of getting there. But sometimes it’s about the action, parts of change and implementing that.
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