Could VR improve the impact of CBT in treating psychotic disorders?
In a paper published in The Lancet Psychiatry, the researchers state that to their knowledge, theirs is the first randomized controlled trial of virtual reality (VR)-based cognitive behavioral therapy (CBT) that has attempted to improve social functioning and decrease paranoid thoughts in people with psychotic disorders.
"The addition," explains lead author Roos M. C. A. Pot-Kolder, from Vrije Universiteit Amsterdam in the Netherlands, "of virtual reality CBT to standard treatment reduced paranoid feelings, anxiety, and use of safety behaviors in social situations, compared with standard treatment alone."
The study compared two groups of similar people with psychotic disorder: one (the intervention group) received the usual treatment plus VR CBT, and the other (the "waiting list control group") continued to receive the usual treatment.
The usual treatment consisted of taking antipsychotic medication, having regular contact with a psychiatrist, and receiving support from a psychiatric nurse to improve functioning in social and community settings, daily activities, and self-care.
Although the study's results are promising, its scope did not include looking at the long-term effects of VR CBT and more research is needed before the treatment could be considered for widespread clinical use.
The researchers also urge that further studies should now compare the "treatment effects and cost-effectiveness" of VR CBT with those of standard CBT, as their study could not rule out that the beneficial effects might have come from just having an additional treatment.
Alternative thoughts and behaviors
CBT is a widely studied and commonly used psychotherapy type that combines cognitive therapy and behavioral therapy. Its methods vary according to the illness or problem being treated.
The underlying principle of CBT is the same as that of all psychotherapies — that is, that feelings, thoughts, and behaviors are interlinked and influence well-being.
The main difference between CBT and traditional forms of psychotherapy, such as psychoanalysis, is that CBT focuses primarily on current problems and how to solve them and less on trying to understand the past.
For example, you may explain in a CBT session that you recently said "hello" to someone you knew as you passed them in the street but they did not respond.
Your assessment of the incident is, "Sally doesn't like me, she ignored my greeting." This makes you feel bad and want to avoid Sally in the future.
The CBT therapist might then encourage you to consider an alternative assessment and a more "neutral" response, such as "Sally didn't notice, me, perhaps she is unwell. Maybe I should call her and see how she is."
Following this insight, the next step would be an "exposure-based therapeutic exercise," where you try to put alternative and more neutral thoughts and behaviors into practice in your own real-life scenarios.
In their new study paper, the researchers note that 90 percent of people with psychosis believe that they are under threat and that others want to harm them. As a result, they avoid being with other people, have few friends and acquaintances, and spend a lot of time on their own.
Although CBT has been used very successfully in the treatment of psychosis, its ability to reduce social functioning and paranoia is limited.
One reason might be that the right scenarios for practicing alternative responses might not arise, or they may be so infrequent that they have no therapeutic value. Another is that there is no chance for the therapist to control the situation so that more relevant — and fewer unwanted — events occur.
VR CBT allows control of exposure scenarios
The VR CBT that the researchers used in the trial allows the scenario to be controlled. Altogether, 116 participants took part in the trial. They were randomly assigned in equal numbers to either the intervention group or the control group (58 in each group).
All continued to receive standard care throughout the study, with the intervention group receiving VR CBT.
The subjects underwent assessments at baseline, 3 months after completion of the CBT treatment, and then again at 6 months. These gave measures of social participation (or the amount of time spent in the company of others), perceived social threat, momentary anxiety, and momentary paranoia.
The VR CBT took the form of 16 sessions lasting 1 hour each over 8–12 weeks. During the sessions, participants were exposed — with the help of a head-mounted display and a gamepad — to four types of VR scenario: on a bus, in a street, in a café, and in a store.
The system allowed the therapist to personalize the scenarios for each participant and produce social cues that triggered paranoid thoughts, fear, and "safety behavior," such as avoiding eye contact.
The therapist could control the number of other parties (the "avatars") in the scenario, what they looked like, and their behavior toward the participants.
Reduced paranoia, anxiety, safety behaviors
As the scenarios played out, the therapists could talk to the participants and help them to explore, consider, and challenge their responses to the cues.
The results of the trial showed that, compared with the controls at the 3-month assessment, the VR CBT participants were not spending more time with others.
However, because the 6-month assessment showed that the control group was spending less time with others and the VR CBT group was spending a little more time, there seemed to be a significant difference in their social participation score at that point.
The results also showed reductions in paranoia and anxiety in the VR CBT group at both the 3-month and 6-month assessment, compared with the controls. But there was no such reduction in the perceived social threat score.
In addition, at the 3-month and 6-month assessments, the VR CBT participants had fewer "social cognition problems" and used fewer safety behaviors.
In a linked editorial comment, Dr. Kristiina Kompus — of Bergen University in Norway — notes that the range of psychotherapy tools is expanding thanks to new technologies such as VR and mobile platforms.
She explains that with VR tools, the therapist can control avatars and situations to give a "more fine-tuned approach to exposure in the context of cognitive behavioral therapy."
There is evidence, taken mostly from studies that have investigated the effect on "simple phobias," states Dr. Kompus, that "virtual-reality-based exposure therapy" could be effective for treating anxiety disorders.
However, there is a need to establish "whether the benefits that virtual reality can bring to therapy extend to complex challenges involving social cognition, such as positive and negative symptoms or social participation in patients with psychosis," she concludes.
"It's important to note that all patients on this trial continued with their usual treatment, and the virtual reality CBT was administered by trained therapists."
Roos M. C. A. Pot-Kolder