Instead of sitting on a psychiatrist’s couch for 50 minutes, then walking out with a prescription for medication, patients sit down in Dr. Howard Gurr’s office, where he straps the headset onto their heads.
The patients view what appears to be a three-dimensional, 360-degree representation of the situation that provokes their anxiety. Gurr walks them through what they’re seeing and feeling.
The patients are placed in an environment based on their specific fear. Then, they take slow steps to overcome their fears. A therapist will start slowly, putting patients who have a fear of flying in a cab before even going near an airport to see how they react, step-by-step.
Now that it is only a few hundred dollars to purchase a set of virtual-reality goggles and the applications used for it, the business is booming. VR therapy started as something meant to help people with post-traumatic stress disorder. Now, it has spread to treat an array of anxieties.
“The treatments I typically use virtual reality for are fear of flying, fear of driving, fear of heights,” Gurr said. “And fear of darkness, for kids.”
Dr. Robert Reiner doesn’t get much rest these days. His spacious, 15-room practice on Manhattan’s Upper East Side is New York City’s hub for virtual reality therapy treatment.
Reiner calls virtual reality “ the most direct treatment you can impose on a patient.”
Reiner said, “especially if you repair something they’re afraid of with something that’s really relaxing. When you’re doing this kind of response, it’s neurologically impossible to experience anxiety.”
What started as a technology of immersive simulations focused on the video game realm has turned into something much more impactful. Virtual reality treatment might take a while, but according to experts, it is more effective than any other type of therapy for treating anxiety disorders.
But virtual reality therapy is costly, and some experts criticize the method as a flawed way to eliminate anxiety.
It could take more than a dozen 45-minute treatments, according to multiple therapists, to cure an anxiety disorder. Reiner whose spacious, 15-room practice on Manhattan’s Upper East Side is New York City’s hub for virtual reality therapy treatment, charges up to $700 per session. If patients can’t afford to see him, the clinic has other doctors in-office who also specialize in virtual reality therapy treatment. Their charges range from just a co-pay to well over $100 per visit.
While some insurance companies, including Empire BlueCross BlueShield, do cover Reiner’s treatment, others do not.
Reiner calls virtual reality “the most direct treatment you can impose on a patient.”
“You repair something they’re afraid of with something that’s really relaxing,” he said. “When you’re doing this kind of response, it’s neurologically impossible to experience anxiety.”
“The treatments I typically use virtual reality for are fear of flying, fear of driving, fear of heights,” Gurr said. “And fear of darkness, for kids.”
Hofstra University advanced doctoral student Tiffany Bruder tries the virtual reality therapy treatment. Bruder is part of Hofstra's clinical psychology program.
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What is virtual reality therapy?
Virtual reality therapy is a form of exposure therapy. Here, the Psious VR system is walking patients through mindfulness.
“The software was so simple that we gave feedback to the company,” Schare said. “It was just sunlight. What about nighttime? What about rain or snow? What about all kinds of hazards?"
Post-traumatic stress disorder is one of the largest parts of virtual reality therapy. This system in Dr. Schare's Hofstra University lab is just one of many throughout the nation that can help soldiers who return to America with severe PTSD.
Virtual reality therapy has been expanding in the United States, with more therapists using this form of exposure therapy to treat patients. The goal is to avoid giving patients medication, trying to avoid the dangerous side effects that could occur, especially during the opioid epidemic.
This form of treatment has been highly popular for soldiers who return from war with post-traumatic stress disorder.
In 1997 and 1998, the journey began to figure out how to use virtual reality as a therapeutic treatment. From Emory University in Atlanta to Hofstra University on Long Island, research has been continuing ever since.
Dr. Mitchell Schare works in the Phobia and Trauma Clinic at Hofstra University’s Joan and Arnold Saltzman Community Services Center. He’s been doing research in virtual reality therapy since the late 1990s, and he was one of the first therapists to truly dive into it, trying to cure people’s anxieties.
The researchers at Hofstra decided to start their own research. Where did they start? Well, they decided to build a car. Yes, therapists indeed built a car.
“Imagine five psychologists building a car,” he said. “It was ridiculous.”
Schare went to a junkyard and purchased a seat from an old Saab and a steering wheel from an old Ford Mustang. The group purchased a Thrustmaster driving game and attached the Mustang steering wheel to it rather than the one that came with the game.
That was Schare’s first experience putting people who had driving anxieties into that type of situation. The goal was to gauge their reactions, along with seeing how realistic it was.
“The software was so simple that we gave feedback to the company,” Schare said. “It was just sunlight. What about nighttime? What about rain or snow? What about all kinds of hazards?
“We found out that we needed all of these things to attend to the people who were fearful of driving.”
Now, VR therapy spreading outside of that realm. It’s a form of exposure therapy that puts people into uncomfortable situations to determine the causes of their anxiety.
“Exposure therapy is based off an extinction model, which means, say, a person is anxious about flying,” Reiner said, “Well, in exposure therapy, you put them on a plane or into virtual reality where they feel like they are on a plane. You put the person right in the middle of it, and the anxious response extinguishes itself.
Thanks to advances in technology, therapists such as Gurr can treat patients at a whole new level.
Gurr said he first encountered virtual reality therapy in the early 2000s. “At the time, it was about $100,000 for the set-up, and we aren’t talking about great resolution, either,” he said.
When the therapists put a patient in the virtual environment, the sense of being in a real place clicks rather quickly as the brain tricks itself.
If you have a fear of flying and visit Dr. Suhadee Henriquez’s Upper East Side office, you will see Jet Blue products throughout the treatment room. It’s set up to soothe patients before they sit in the actual airplane seat where Henriquez conducts the therapy.
Once the patient is seated and buckled in, Henriquez begins talking the patient through the process of taking a trip on a plane.
“I usually start where the person has the fear, like at home, in the cab on the way to the airport, at the gate or even on the aircraft,” Henriquez, who started out as a flight attendant, said. When she puts patients in the chairs, she puts them in real-life experiences, known as “in vivo” in the therapy realm.
A human’s brain adapts quickly to the virtual reality glasses, almost getting tricked into thinking the VR setting is real. However, it isn’t really a trick. The images seen through the VR goggles allow the brain to slow down its primitive fight-or-flight response.
In talk therapy, as opposed to exposure therapy, the patient engages the frontal part of the brain, which is used in reasoning. In exposure therapies such as virtual reality therapy, the patient responds with the amygdala, which is in the back part of the brain. The amygdala is the area of the brain that detects fear and prepares for emergencies.
What happens when a patient experiences fear or anxiety, Gurr said, “is the amygdala is over-reactive and is starting to shoot off too early. This fight-or-flight syndrome is a normal process, but … it’s coming up at the wrong time and place.”
As the VR goggles help desensitize the patient’s brain to the environment that has evoked the fear, Gurr, Henriquez, Reiner and therapists like them attempt to reteach the patient how to breathe. Deep, slow breaths enable the amygdala to react differently, preventing it from firing too early.
Patients “start gaining control,” Gurr said. “They become more capable of not going into this fight-or-flight syndrome.”
Criticisms
Just as in any field, there are plenty of criticisms that could be tossed around. For this specific type of exposure therapy, since it is still developing, therapists who practice other forms are treatment are often quick to jump to conclusions.
At White Plains Hospital, doctors use a combination of cognitive behavioral therapy, a type of talk therapy that focuses on a person’s reaction, and exposure therapy—but not virtual reality therapy.
A hospital official said that while virtual reality therapy can be helpful for PTSD and other disorders, patients ultimately need real reality, not just virtual reality.
“We believe that to overcome phobias and anxieties, one must enter the actual situation, in manageable steps and with a trained helper, and learn ways to manage and overcome the anxiety,” Judy Chessa, coordinator of the Anxiety and Phobia Treatment Center at White Plains Hospital, said in an email.
Schare has a simple sentence for the nay-sayers.
“People who criticize the therapy don’t understand the therapy,” Schare said.
Schare said what makes VR therapy so effective is that it taps into all of the sensory systems to make things as real as possible.
The therapists don’t take the criticism lightly. They say they want to hear out critics and answer the questions they have.
“Whenever you come out with a new therapeutic approach, there are always people who will find fault with it, say it’s simplistic or say it’s not effective,” Gurr said. “It challenges the standards they live by.”
As the virtual reality therapists said, outsiders see it as an ineffective treatment because it doesn’t address the deeper issues. Some who use VR therapy agree that these hidden problems need to be addressed. Others do not.
Schare, for one, says he does look at the deeper issues. He said the treatment helps not only pinpoint why someone is scared by something, but also helps identify other problems that may arise during treatment.
“They aren’t so sure they want to go on with the treatment because going on with the treatment means spending a week with their in-laws, and they really don’t want to do that,” Schare said. “There are other issues.”
“Whenever you come out with a new therapeutic approach, there are always people who will find fault with it, say it’s simplistic or say it’s not effective,” Gurr said. “It challenges the standards they live by.”
“I usually start where the person has the fear, like at home, in the cab on the way to the airport, at the gate or even on the aircraft.” - Dr. Suhadee Henriquez
Different ways VR therapy works
Dr. Keith Grimes brings a different perspective to virtual reality therapy.
“All throughout my career, I’ve tried to put technology and medicine together,” Grimes, a general practitioner in the United Kingdom, said via Skype.
What Grimes does is different from how most doctors use virtual reality in their treatment. He uses it with patients who have pain, rather than any disorders.
“I had patients coming into me with not PTSD, but with pain,” Grimes said. “With my patients, we explored using it and started doing it. I found out virtual reality could be a low-cost, effective way of reducing pain and anxiety.”
Grimes treats patients who have severe wounds or are going into procedures that are hard to treat with pain relief medication. The virtual reality calms them down prior to treatment.
His patients have been more open to the treatment than his peers in Britain, he said, some of whom have thought about virtual reality therapy but refuse to utilize it in their treatments.
Once Grimes’ patients say they are interested in VR therapy and agree to try it, he offers them a series of experiences that they will encounter once they put the goggles on. These experiences vary from watching a Cirque du Soleil performance, sitting in a relaxing environment or even playing a game, such as Bear Blasting, which involves knocking over teddy bears with fireballs.
“Virtual reality delivers emotion, which is the big thing that makes people feel less anxious and serves as a distraction,” Grimes said. “If you get them to play a game or something, the focus increases the effect.”
Fortunately for his practice, this method has been quite successful.
Said Grimes, “Virtual reality is not a magic box. It has limitations. But it’s been pretty successful.”
In the PTSD realm, virtual reality is a key to healing people. The treatment is usually centered on soldiers who have come back from war.
Dr. Skip Rizzo, director for medical virtual reality at USC’s Institute for Creative Technologies, presented some of his research at the 2018 VR Expo in England. In this 149-slide presentation, he thoroughly breaks down how virtual reality therapy has made an impact on so many lives.
In one of his slides, Rizzo, who runs multiple conferences and is considered America’s most prominent virtual reality expert by his peers because of his advanced research in the field, discusses how the technique helps soldiers prior to combat, using Stress Resilience In Virtual Environments, or STRIVE. Ninety-one percent of soldiers tested said they believed STRIVE could help them mentally prepare for stressful events, and 88 percent of those surveyed said that visualizing or rehearsing a situation prior to its occurrence would help them survive.
The Oculus Rift is one of the most popular virtual reality tools in the world. Consumers can purchase it starting at $399.
Dr. Robert Reiner uses a series of different virtual reality headsets. Pictured here is one of them that immerses people in a new environment.
What technology do the therapists use?
Many virtual reality therapists are using the Oculus Rift virtual reality goggles made by Oculus VR, a division of Facebook, but this isn’t the only piece of technology that’s available.
The Oculus Rift, created by entrepreneur Palmer Luckey, isn’t just your normal virtual reality toy. It’s not just a game. It is putting people in a whole new world, one that will change virtual reality therapy for the better.
Other players in the market include HVS Image, located in Britain. The devices enable patients to step back for a bit, going into a world outside of the doctor’s office. How’s this different from Oculus?
“We provide very realistic environments,” Beth Hawthorne, director at HVS Image, said. “It’s such an immersive experience. It depends on what technology is used. It’s pretty new in terms of the therapy side.”
Another device is the Psious VR Therapy system, which Drs. Robert Reiner, Howard Gurr and Suhadee Henriquez also use.
The Psious system uses a smartphone app, which connects the doctor’s computer to the phone. The phone attaches to the headset. When a patient puts the headset on, she can’t even tell she is actually looking at a phone screen.
Reiner also uses biofeedback to help patients see how they are physiologically responding to stress by monitoring heart rate, blood pressure, muscle tension, blood flow and even brainwaves.
"The brain is capable of doing all of this stuff itself," Reiner said. "It's about learning how to unleash its secrets."
The Future
"I see a standard operating procedure, so it’s mostly administered by non-doctors, like nurses or something like that. This is what I’m thinking of in terms of primary care.” - Dr. Keith Grimes
Dr. Howard Gurr uses augmented reality to treat patients who have a fear of spiders.
Now that more people are finding out about this form of therapy, the field is expanding.
The technology that therapists are using is getting cheaper and more efficient. The virtual reality spaces that the therapists are putting into patients’ field of vision are increasingly realistic.
Change is on the way, and each therapist has his or her own take on what’s coming next for this field.
“I see there being Stadler headsets, so they don’t need to be plugged into anything,” Grimes said. “It’s just a standard headset that you put on the side and when the patient comes in, you put it on. I see a standard operating procedure, so it’s mostly administered by non-doctors, like nurses or something like that. This is what I’m thinking of in terms of primary care.”
Virtual reality, Grimes said, can help people who are suffering with chronic pain. Potentially, it might get to the point where patients can have their own devices to practice the specific therapeutic techniques at home.
“More professional-grade virtual reality will be used for doctors and nurses to practice simulations, education and training,” Grimes said. “I’m looking at how virtual reality could be used as a place to actually consult patients. We could have doctor and patient in VR together.”
But that’s not how Schare feels. He believes patients need to be guided by their therapist.
“I don’t think that’s appropriate,” he said.
That’s part of why Schare thought of an idea to continue his research to further advance this field.
Schare is testing out what he called a “distanced version of therapy versus an in-person version.” The goal, because he has patients from around the country come to his Hofstra clinic, is to have patients worry less about traveling to his facility, especially if they are scared of traveling.
Even then, that might not be the future of this field.
“I don’t believe the future is virtual reality in itself,” he said. “I really think augmented reality”-- like Pokemon Go, in which the reality is presented in front of you -- “is where the future of this treatment has to go. We have to be able to cross between virtual reality and augmented reality depending on the problem.”
Gurr has an app on his smartphone that he uses to bring the augmented reality to patients. At one point, he takes the phone, puts it over a barcode, and then spiders begin to "walk" on his hand. This is one of the ways he treats people for arachnophobia.
He also strongly believes that the evolution of virtual reality is just beginning. He sees the field becoming more robust, and he has high expectations moving forward.
“It’s the gold standard of treatment now for phobias, but it will become the method of choice,” Gurr said. “The dream is coming up with an environment where there is an artificial intelligence that could be used to help the person come along and be their guide.”
The journey into a new world is just beginning.