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31 January 2024

Daniel Freeman: “Psychosis is seen as scary. It’s the last taboo”

“Professor Paranoia” on what works in psychiatry, and why he’s asking patients to put on virtual reality headsets.

By Sophie McBain

In a quiet corner of an open-plan office inside Oxford’s Centre for Experimental Psychology, I put on a virtual reality (VR) headset and was transported to a coffee shop. To my right was a glass counter with cakes and muffins, and to my left stood a tall man who turned to meet my gaze, his eyes a piercing blue. A customer at the counter paid and shuffled off, leaving his wallet behind. In this VR game, gameChange, the challenge is to call after the man to return his wallet. It’s the kind of interaction you wouldn’t think twice about, unless you’ve ever known extreme social anxiety. GameChange has been created as a form of therapy for people with psychosis, helping them to tackle the fears and paranoid delusions that prevent them from leaving their home or talking to strangers.

Daniel Freeman, a professor of clinical psychology at Oxford University, believes VR may offer the perfect therapeutic medium to help people overcome paranoid delusions. For some patients, walking to a café – even with a trusted therapist – would be too overwhelming. “In VR, the person is able to hold the idea that this isn’t actually real, and that just brings down the temperature to a level where they can actually make the learning,” he said. Only by starting out in the virtual world can they begin confronting their anxieties and challenging the distorted ideas that drive them. In a medical trial, published in the Lancet in 2022, Freeman and his team found that gameChange delivered “significant reductions” in agoraphobic distress and avoidance, especially for those with the most acute symptoms.

Freeman hopes VR therapy will, as the name suggests, be a game-changer not only for patients but for the NHS. In November, gameChange became the first VR mental health treatment to be recommended by the National Institute for Health and Care Excellence. With gameChange, patients don’t need to be guided by a clinical psychologist – which is fortunate, because the underfunded health service has too few of them. Instead, other staff can be trained to guide people as they complete progressively harder challenges at home.

Freeman is 52, tall and dressed all in black, with cropped white hair and a serious manner. His research assistants have nicknamed him “Professor Paranoia” because this has been his primary interest for the past three decades. As he writes in his new book, Paranoia, when he began training at London’s Institute of Psychiatry in the early Nineties, the prevailing view was that paranoia was a symptom of severe mental illness and best treated with medication. Doctors rarely spoke to patients about their paranoid beliefs, for fear of reinforcing the delusions. But Freeman has spent most of his career trying to demonstrate that psychological interventions such as cognitive behavioural therapy (CBT) can help those suffering from psychosis. He argues that, far from being alien, incomprehensible experiences, “paranoia arises from a very ordinary aspect of human thinking, which is about trust and mistrust. These are tricky decisions; we all get them wrong to varying extents and our patients are, for a number of reasons, getting it wrong more severely.”

Freeman has used VR to demonstrate how commonly we reach paranoid conclusions. In 2006 he invited 200 students to ride on a virtual London Underground carriage. The other VR passengers were engineered to appear neutral, and yet around a third of the trial participants reported paranoid thoughts about the avatars: they said they’d been laughed at or felt threatened. “Mistrust is corrosive, inside individuals, relationships and society,” Freeman said, and he has been charting its rise in the UK. Alongside growing political mistrust and conspiracy thinking, Freeman has documented high levels of social mistrust. A survey he commissioned in 2023 found that 40 per cent of people said they felt more fearful of others than they should do. Freeman believes one reason for this may be rising inequality, because his research has shown that feeling vulnerable or having low self-esteem contributes to paranoid thinking.

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Until the pandemic, Freeman’s research into mistrust and conspiracy attracted only muted interest. But it has become a hot topic. In 2020, he and his researchers scoured the internet for the wildest Covid conspiracies they could find, expecting that at most one in 20 people would believe in them. Instead, a survey of 2,500 adults found that one in five said they believed the virus was created by Jews, and a quarter blamed the World Health Organisation and UN for Covid. Has helping people overcome paranoid delusions taught Freeman about how best to challenge conspiracy theories? “The first bit is no surprise: it’s being genuinely curious,” he said. “I want to get in their shoes and understand… how they’re perceiving their environment.” He seldom tells people directly that they are wrong; instead he tries to help them consider an alternative way of seeing the world. “Any time you start challenging a person’s current position it’s going to become stronger. This is why people arguing in the pub don’t change people’s minds.”

Freeman hopes that once society recognises that paranoia exists on a spectrum, psychosis will be less stigmatised. When he was studying at Cambridge even the psychology students didn’t discuss mental illness, and he is glad we talk about conditions such as depression and anxiety much more now. “But psychosis is seen as scary. It’s the last taboo,” he said. The evidence suggests talking therapies may be one of the most effective interventions for people with psychosis: a clinical trial for Feeling Safe, a CBT programme Freeman developed for people with persecutory delusions, found half of the participants recovered and a further quarter experienced improvements. Yet, due to chronic underfunding, too few people with psychosis are given access to high-quality therapy: Freeman estimates only around one in ten. He said mental health services are the most stretched he’s ever seen them.

Sometimes he’s almost “embarrassed to talk out loud” about the problems. “A lot of research I’ve done shows that if you sleep badly, that’s going to make your mental health and psychotic experiences worse. That seems very obvious to me. And if I speak to anyone in the general public… everyone gets that. And yet that’s not how it’s viewed in mental health services, where poor sleep has been considered a consequence of psychotic experiences.” He has shown that when people who are hospitalised with psychosis receive CBT for their sleep problems, they are discharged quicker. Again, this is rarely available to patients.

Often Freeman will meet patients who have spent decades in mental health services and made little improvement. Is the problem that we have too few treatments, or that people aren’t accessing the ones we do have? “Both,” he said. Freeman is frustrated at the speed of change. “I just want to get on and make change.” He approaches his work with urgency, and alongside his teaching he is working on an online version of Feeling Safe, and testing VR therapy for people with needle phobia and young people with psychosis. He works seven days a week, “so there’s not much life in the work-life balance. But I’m lucky – I like what I do.”

As I’d never tried a VR headset before my visit, Daniel Freeman thought I should have a go on Beat Saber, one of the most popular VR games. And so, before I left his offices, I waved two light-sabres in time to high-energy techno music, until he had to warn me that in my enthusiasm I had edged forward and was about to bash my fists into his TV screen. One of Freeman’s colleagues recently reported she had been worried when one of her patients wasn’t opening her door or responding to her calls, until she learned that she was playing VR games. That’s another way VR can improve mental health: “You can’t ruminate while playing Beat Saber,” he said.  

[See also: Are you ready for Elon Musk to read your mind?]

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This article appears in the 31 Jan 2024 issue of the New Statesman, The Rotten State

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