For some people, the prospect of standing in a queue, visiting the supermarket, or even ordering a coffee can be terrifying. Up to 12 per cent of the country’s population will experience social anxiety disorder at some point in their lives, according to the latest Adult Psychiatric Morbidity Survey, which monitors the prevalence of mental illness in England. Social anxiety is the third-most-common psychiatric condition after depression and alcoholism. Roughly 6 per cent of the population will suffer from generalised anxiety, 5 per cent will suffer from panic attacks, and 2 per cent will report symptoms of obsessive-compulsive disorder. Many more live with these conditions without diagnosis.
Day-to-day interactions can exacerbate symptoms. What might be viewed as routine for the majority of the population can trigger a “real struggle” for those with anxiety, says Dr Ramesh Perera-Delcourt, a clinical psychologist at Oxford VR, a spinout from the University of Oxford. The company uses virtual reality technology to “enhance” therapy treatments for anxiety. “What other people might take for granted is a battle for them,” he says. “This affects not only their mental health but their overall quality of life… they experience fear in public situations, especially when they’re alone. It can be really debilitating and affect their capacity to carry out a job or even socialise.”
Founded in 2017, Oxford VR creates immersive therapy sessions with technology similar to that used in films and video games. “The idea is not to replace or substitute traditional therapies,” Perera-Delcourt says, “but rather to complement them.” He goes on to explain that: “It’s not the same as other forms of traditional exposure therapies where, say, you might show someone with arachnophobia a picture of a spider for a length of time until they became more at ease with the image. The VR scenarios allow us to coach patients, over time, in a controlled setting.”
Oxford VR’s social engagement series launched earlier this month. It puts patients with various forms of social anxiety into different virtual settings, including a shop, a bus ride and a street scene. Putting on a VR headset, patients use two handheld controls to interact with the environment. The VR programme can be delivered through a VR-ready desktop computer or laptop, or smart television. Once in the VR setting, a virtual coach guides patients who have to complete tasks, much like in a video game. This might involve, for example, locating and buying certain items on a shopping list. Each session lasts about 30 minutes. The number and intensity of the sessions depend on the severity of a patient’s anxiety.
Benn Garnish, lead animator at Oxford VR and head of the company’s studio, previously worked on visual effects in film, including Harry Potter and the Deathly Hallows: Part 2 and Wonder Woman. “As patients become more confident [with their progress or in the setting],” Garnish says, “we might introduce more complicated situations. They might need to speak to other characters within the programme, or we might introduce more characters around them, to create a bigger crowd.”
The graphics used in Oxford VR’s virtual environments are, Garnish admits, “not comparable” to gaming platforms such as “PS4, Xbox One or similar”. Instead, he would accept that Oxford VR’s settings are “more like [that of] a generation [of video game artwork] or two ago”. But that is deliberate, he says. “The idea wasn’t to make the technology hyper-realistic. You want it to be realistic enough for the settings and tasks to be believable and like the real world. But, actually, if you had a hyper-realistic setting with really, really life-like settings, then you run the risk of the patient being overwhelmed or disoriented.”
June Dent, Oxford VR’s clinical partnerships director, says that: “Patients report that the scenarios feel very realistic and evoke the sorts of emotions and thoughts that are unpleasant and usually avoided. On the one hand, they don’t feel safe. But on the other hand they know they are in VR and are safe.”
One patient, who prefers to remain anonymous, suffers from such severe social anxiety that he is often housebound for days at a time. He says that Oxford VR’s social engagement series is helping him slowly, but surely. The likeness to a video game helps to make some difficult situations “really good fun”, he says. “It’s very real. You can use the VR to practise being in those places to overcome the negative intrusive thoughts to build your confidence, so when you go back into the real world you feel a lot better because you say to yourself, ‘I was able to do that in VR so it’s OK.’”
Dent has no concerns over the clinical validity of VR, which she stresses is rooted in more than 20 years of research by the Department of Psychiatry at the University of Oxford. All of Oxford VR’s programmes, she says, have been developed with patients with “lived experiences of serious mental health conditions”, involving numerous consultations with clinical psychologists. “Oxford VR gives high priority to making sure that the programmes do work, and has conducted trials to test them out. Our Fear of Heights programme was evaluated in a randomised control test (RCT) published in The Lancet in 2018 and found impressive clinical results. And the social engagement programmes launched this month were designed for use in a big RCT across five National Health Service centres.”
Currently, the company’s social engagement programmes are available on the NHS via Improving Access to Psychological Therapies, as well as through other mental healthcare providers, such as some community projects in individual trusts. Oxford VR’s aspiration, says Dent, is that its programmes will become widely available to help people with “life-interrupting” mental illness.
Nicky Lidbetter, the chief executive officer of the charity Anxiety UK, welcomes the growing role of technology in mental health treatments, and highlights the “transdiagnostic” potential of VR to treat anxiety disorders. Lidbetter hopes that “this type of support will soon become widely available to the many thousands of individuals affected by anxiety”.
Dent is hopeful that VR can help to streamline pathways to treatment and relieve some of the pressure on the NHS. “Exposure therapy and cognitive behavioural therapy (CBT) are two of the most effective treatments for phobias, but there are a number of drawbacks, both general and specific.” She highlights that there are far more people with disabling mental health problems than there are therapists to treat them. “Waiting times can be long, treatment itself can be delivered inconsistently, and outcomes can be variable. Furthermore, people can feel a great deal of stigma about asking for help, and talking therapies do not suit everyone.”
By automating aspects of mental health care – Oxford VR’s social engagement series can be delivered without a therapist present, as the virtual coach can guide patients through programmes – Dent believes that more people may be able to receive help at any one time.
The potential of VR in the mental health space is “really exciting”, says Garnish, who hopes Oxford VR can build on its existing social engagement series. “We will be looking to create even more scenarios, including an office setting, to help people overcome their problems.”