How VR will conquer your worst fears

When I was a little kid, I washed my hands so often that my skin bled raw. I had just learned what germs were and in my imagination little disease-ridden critters crawled all over me every time I touched something new. So a few times an hour, I would run to the sink and try to scrub them off. Not really knowing what to do, my mom bought me a pair of pretty white princess gloves and hovered to make sure I never took them off.

I got over obsessively washing my hands, but it was the beginning of a lifetime of finding terror and anxiety in odd places. I’ve been crippled with panic over irrational fears of sharks, sweat, public restrooms, and, after violently slamming into a tree the first time I got behind the wheel, driving a car.

My heart still races nearly every time I drive. So when I went to the The Virtual Reality Medical Center in San Diego, which uses VR programs to treat phobias and conditions like post traumatic stress disorder, I wondered if perhaps there was a VR cure for the gnawing panic I feel every time I slip into the driver’s seat.

At the center, in a drab office park on the outskirts of the city, the first VR program I tried was one designed to treat PTSD in returning combat veterans. For over a decade now, treating vets with VR has shown promising results. I strapped on a headset and crawled through the narrow streets of Iraq in a humvee, patrolling the roads from the passenger seat as explosions rattled in the distance. It felt like a video game—too fake, I imagined, to successfully treat anything.

But when I took a seat in a swivel chair behind a plastic, arcade game-style steering wheel, suddenly the virtual world became very, very real. This time, I was in the driver’s seat, cruising the sunny streets of some nebulous American suburb. I started visibly sweating and felt my heart rate soar. Entering a roundabout where virtual cars whooshed past me headed every which way, I felt nearly certain I was going to die.

“See?” said Dr. Mark Wiederhold, who runs the center with his wife, commenting on my sweating brow. “I told you it would feel real.”

He cooed that I was doing well, even as I swerved between lanes and, in a spiraling panic, ran a red light.

Two hours later, I sat in a rental car in the parking lot, still trying to shake off the panicked feeling. I sat there for nearly 20 minutes, trying to work up the nerve to drive. Typically patients endure three or four therapy sessions before trying out the VR, and then have at least five or more virtual sessions after that.

In hundreds of therapists’ offices across the country, virtual reality has already changed how phobias are treated. But in the not-too-distant future, it is likely that a VR set will become standard in every psychologist’s tool bag.

There’s really no good reason for it not to. Study after study has shown that VR is more effective at treating certain anxiety disorders than the more traditional, non-virtual methods. At times, the results have been stunning: one 2006 study involving people afraid of planes found that virtual exposure to flying was just as effective as therapy that involved going to the airport. More than three-quarters of people who received the VR treatment were willing to fly.

Since the 1950s, when the South African psychologist James Taylor developed what he called “graduated exposure therapy” to treat pathological fears, exposure therapy has been widely considered the best method to treat fear. The idea is to gradually expose a patient to the object of their anxiety, while using therapy to help them become less sensitive over time. Taylor, for example, exposed compulsive hand washers to anxiety-inducing situations and then prevented them from washing their hands. It works because overcoming fear is about learning to predict what happens when exposed to it, and the repeated exposure makes fear predictable. Often, therapists use some combination of what’s known as imaginal treatment and “in vivo” treatment, both asking patients to imagine their fear and confront it in real life.

What’s interesting about virtual reality is it offers a middle ground: patients can approximate the experience of exposure, without actually having to be, well, exposed.

More than two decades ago, a psychologist and a computer scientist published the first paper examining VR as therapy, finding that it successfully helped patients overcome a fear of heights. The next year, a pair of scientists published a paper on the successes of using it to cure arachnophobia, or fear of spiders. Among their patients was a woman they dubbed “Ms. Muffet,” whose fear compelled her to duct-tape the doors and windows of her bedroom each night.

But until recently, VR has been prohibitively expensive and the technology has been clunky.

In the 1990s, the VR equipment researchers relied on was hefty, burdensome and typically cost tens of thousands of dollars. The last Oculus Rift development kit, on the other hand, weighs less than a pound and cost $350. Smartphones, which come with sophisticated built-in gyroscopes and accelerometers and can slip into VR headsets like the $19 Google cardboard, have been a particular boon to the field. Companies like Psious can now make VR accessible to the average licensed therapist on the cheap. Thanks to the smartphone, wrote Wired’s David Pierce last March, VR has, over the past two years, gone “from impossible to impossibly easy.”

Virtual reality works because in the brains of phobics, the virtual world activates the same pathways as confronting a fear in real life. When you’re afraid of spiders or driving or flying, being immersed in a 3D-simulation of your fear triggers a similar emotional response. It’s why a simulation of the streets of Iraq seemed to me like a crudely-rendered video game, but sitting behind a plastic wheel in a swivel chair felt distressingly real. Wiederhold told me that he and his wife have found that patients will respond emotionally to incredibly crude graphics. He said that making an environment seem too real can actually be a bad thing, exposing a patient to too much, too soon, like asking an arachnophobic to hold a spider after one hour of therapy.

Virtual reality isn’t actually changing anything about how phobia is treated. Before entering the virtual world, patients still have to understand how their anxiety works and develop some kind of skills for coping with it. But it’s a replacement for that final step of facing your fear, a replacement that puts that step under a therapist’s control and allows for more gradual exposure, rather than going straight from the therapist’s office to a plane. In other words, VR makes it less likely that a patient will totally freak out.

“If have a patient go out and drive, I can’t control the weather or the traffic,” said Elizabeth McMahon, a Bay Area therapist who has treated patients with VR since 2010, and now uses a set made by Psious. “In VR, I can have the road be windy or not. It can be sunny or rainy. On a real plane, you can’t control the level of turbulence. But on a VR plane you can. And your therapist is right there with you through the whole thing.”

McMahon said that the nearly two dozen patients she’s treated for fear of flying with VR have all gotten onto planes and more quickly than with traditional treatment. After five sessions, she’s had patients go from getting drunk to get on a plane, or walking off before it takes off, to telling her how beautiful it is to look out the window. The Wiederholds have similarly found drastic reductions in the amount of therapy patients need before dealing with their fear.

In the past five years, McMahon told me, VR “has gone from cutting edge to what should be standard best practice.”

There are downsides. The Wiederholds are studying what kind of patient is most receptive to VR, and have found that patients who seem to have trouble imagining things aren’t very responsive. For other patients, the level of exposure might be too intense. And VR causes motion sickness in some people, making VR therapy not a particularly attractive option.

But Walter Greenleaf, an early pioneer of VR in medicine and visiting scholar at Stanford’s Virtual Human Interaction Lab, told me that VR-assisted therapy has proven to be more engaging for patients than traditional exposure therapy methods, leading to faster, longer-lasting results. He said that it also seems to carry less stigma, encouraging more people to seek out treatment and stick with it when they do.

“What’s going on with phobias is only the crest of the wave for how VR is going to impact cognitive wellness and mental health,” he said. “They’re just an easy example of how VR impacts the brain.”

Greenleaf cautioned, though, that while the hardware for VR is finally there, software environments for creating treatment programs still have a way to go.

He’s also concerned that commercial companies may market VR programs designed to “treat” phobias outside of the watch of a licensed therapist. It can be hard to know your own limits. The role a therapist serves is to push a patient when they need to be pushed, and pull them back when they’ve gone too far.

“It’s possible to re-traumatize yourself,” he said. “I know there will be someone who commits suicide who uses VR in an inappropriate manner. It’s a very powerful technology.”

More than 12 percent of U.S. adults experience some kind of anxiety disorder over their lifetime. It’s unclear yet how virtual reality will transform industries like consumer entertainment and shopping and travel. But the vision of how VR will reshape mental health is already fully formed.

This story is part of Real Future’s Fear Week.