CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING

Volume 22, Number 1, 2019

ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2018.29136.bkw

Virtual Reality Therapy:

Emerging Topics and Future Challenges

Brenda K. Wiederhold, PhD, MBA, BCB, BCN,1,2 and Giuseppe Riva, PhD3,4

Abstract

Virtual reality (VR) is no longer a fantasy or a novelty to be used for pure entertainment. It is a technology that
has, over the past three decades, taken hold and enriched multiple areas of science, most notably healthcare.
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Starting from these premises, this special issue will specifically investigate how VR and other important
advanced technologies are being adopted and adapted for use in the healthcare field, with a specific focus
toward the diagnosis and treatment of mental health disorders.

O nce merely the territory of science fiction authors and

hopeful dreamers, virtual reality (VR) is no longer a
fantasy or simply a novelty to be used for pure entertainment.
It is a technology that has, over the past three decades, taken
hold and enriched multiple areas of science, most notably
healthcare, and has become an integral part of our everyday
reality.1,2
At Cyberpsychology, Behavior, and Social Networking,
we make it our responsibility to ensure that the articles
published in this journal align with the trajectory of impor-
tant technologies and how they are impacting psychology
specifically and healthcare more generally. To this end, we
are pleased that this special issue is the first of many to be
published in the coming months and years that will specifi-
cally investigate how VR and other important advanced
technologies are being adopted and adapted for use in the
healthcare field.3–6
When the journal released the call for papers for this
special issue on VR therapy, we were delighted with both the
quality and the variety of the work submitted in response.
From genetics to training, from patient assessment to treat-
ment, researchers are using VR to expand, and challenge,
previously held scientific principles and limitations.
The first of many exciting articles in this issue addresses
the rapidly growing field of genomics and how individu-
alized genetic information is provided to the general public.
The current in-person models of counseling patients on the
interpretation of their own genetic information is inade-
quate for the large-scale information delivery that will soon
be necessary. In light of this, Persky et al. investigated the
effectiveness of the adoption of two different digital tools
for this purpose: a non-immersive Internet-based platform
and a simulated VR-based consultation with an avatar
physician.
One of the most dramatic areas of growth featured in this
issue is in the use of noninvasive technologies such as VR
as an adjunct to invasive medical and surgical procedures. It
is well established that distraction is an effective pain
management technique both during procedures and in re-
covery, and immersive technologies such as VR enhance
the pain-reducing effect. But just how immersive does that
intervention have to be? This is the question that Mosso
Vasquez et al. hoped to answer in their study of surgical
patients. Patients were randomized into two groups: one
using a desktop head-mounted display and the other using
mobile VR.
Beyond helping to reduce the distressing effects of sur-
gery, it is becoming clear that VR treatment for certain
conditions may even prevent the need for surgery altogether.
In their article, Li et al. examine the effect of VR-based
visual training in patients with intermittent eye misalignment
as an alternative to surgical correction. After 6 months, eye
positions had improved in all patients, indicating that VR
technology may offer an effective, noninvasive alternative to
surgery.
One of the first areas explored in behavioral healthcare in
the 1990s was VR exposure for anxiety disorders, and its
success has been shown in studies conducted around the
world. In their study, Suso-Ribera et al. look at data from
three randomized controlled trials to examine the efficacy of

1
Virtual Reality Medical Center, La Jolla, California.
2
Virtual Reality Medical Institute, Brussels, Belgium.
3
Applied Technology for Neuro-Psychology Lab, IRCCS Istituto Auxologico Italiano, Milan, Italy.
4
Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy.

3
 4 WIEDERHOLD AND RIVA
three different exposure-based treatments for small-animal
phobia: in vivo, virtual reality, and augmented reality (AR).
Hoping to take VR exposure therapy a step further, Tardif
et al. examine the use of both tactile and haptic feedback as
adjuncts to VR therapy in the treatment of spider phobia.
Participants with a fear of spiders were randomly assigned to
three groups: visual stimuli only, visual plus tactile stimuli,
or visual, tactile, and haptic stimuli (the feeling of actually
crushing a spider).
VR researchers often use the measure of a patient’s sense
of physical presence (the feeling of ‘‘being there’’) in vir-
tual environments to indicate the effectiveness of particular
immersive scenarios. Attempting to move beyond this, in a
study of patients with social anxiety disorder, Felnhofer
et al. explore whether social presence in VR has an effect
on treatment efficacy as well. Participants were exposed
to three social tasks in an interactive virtual environment.
Both subjective ratings and heart rate responses were
recorded.
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In their two-phase study, Riches et al. focus on the ability
of VR to enable real-time assessment of paranoid ideation
and of associated social performance. During the second
phase of the study, the VR environment proved immersive,
and exposure to it elicited high state paranoia and negative
components of social performance. Results suggest that the
VR scenario may be useful as both an assessment and a
treatment tool for individuals who experience paranoia in
social situations.
Due to its experiential nature, VR cue exposure therapy
(VR-CET) has been shown in several studies to be an ef-
fective treatment for weight-related disorders. In a 6-month
follow-up on a previous study, Ferrer-Garcia et al. assessed
the symptoms of a subgroup of patients with bulimia nervosa
and binge eating disorder who still showed active episodes of
binge eating at the end of a structured cognitive behavioral
therapy (CBT) program. These patients were randomly as-
signed to one of two additional treatments: additional CBT or
VR-CET.
Multiple studies are beginning to prove the utility of VR
for seniors across the continuum of care—from assessment
to prevention to treatment. Gamito et al. worked with a group
of older participants to determine whether VR technology
could be used to halt or slow the cognitive decline that often
comes with age. After participants executed activities in a
VR environment, measures showed significant increases in
visual memory, attention, and cognitive flexibility scores,
signifying that VR may be an effective intervention for
cognitive stimulation training in the elderly.
In their study, Negro Cousa et al. compare immersive and
non-immersive 360 environments for evaluating memory
function. The memory task involved recalling items from the
360 environment. Results indicate that memory encoding
was improved only in the non-immersive world. These
findings and possibilities for future research on memory as-
sessment are discussed.
Lastly, Riva et al. explore the meta-analyses and system-
atic and narrative reviews published in this field in the last 22
months. The available studies suggest that VR compares
favorably to existing treatments in anxiety disorders, eating
and weight disorders, and pain management, with long-term
effects that generalize to the real world. They also suggest
that the efficacy of VR in these areas can be explained by
recent neuroscience research: VR shares with our brain the
same mechanism—embodied simulation.
In sum, the articles included in this first of many special
issues centered around VR and AR highlight the endless
possibilities for immersive technology to improve health-
care. However, we also believe that there are two open
questions that still have to be addressed. (1) What is the best
way to improve the long-term efficacy of existing ap-
proaches? (2) How can we improve the dissemination of VR
in clinical settings?
On the one hand, we need new technological solutions.
A first step is moving VR from a single- to a multi-user
setting. Single-user VR forces most patients to experience
VR only in their therapist’s office. Alternately, if they are left
alone to experience scenarios in a fully immersive VR world,
they may not receive the support they need to manage their
problems in a healthy and lasting way. In fact, lasting change
requires the ability to face the situations that cause distress
and learn how to cope with them with the help of a therapist.
Shared VR, allowing the online connection between patient
and therapist, can revolutionize the delivery of online ther-
apy and improve the efficacy of VR treatments.7
Additionally, we need new tools to simulate not only the
external reality but also the internal one (bodily self-
consciousness; Riva et al.). In fact, existing VR systems do
not consider a peculiar feature of the human body—the
multisensory integration of internal inputs (interoceptive,
proprioceptive, and vestibular)—that constitutes our inner
body dimension and plays a critical role in the development
of many pathologies.8 The new technological approach of
‘‘sonoception’’ (www.sonoception.com)9—the use of wear-
able acoustic and vibrotactile transducers to stimulate both
mechanoreceptors in different parts of the body (the stom-
ach, the heart, and the muscles) and the otolith organs of the
vestibular system—could be a possible solution to this
problem. In particular, the integration of sonoception with
VR and different state-of-the-art, neurofeedback/biofeed-
back and brain/body stimulation technologies may allow the
emergence of new therapeutic tools able to target all the
different pieces of the human experience, including our
multisensory integration processes.10
On the other hand, technology is not enough. We also need
compelling content able to immerse users in an alternate
reality. Patients are not passive consumers of VR content;
they bring their own individual thoughts, needs, and emo-
tions to the worlds they inhabit. So, effective VR experiences
are built around narratives.11 Successful stories challenge
previous conceptions, invite users to engage with the mate-
rial, and recognize the power of untethering users from their
physical world and transporting them into another. That has
been true since the earliest forms of storytelling and will
remain true as VR continues to evolve.
A final challenge is related to the dissemination of VR
therapy. Even though multiple trials and reviews have
demonstrated the efficacy of VR in the treatment of anxiety
disorders, eating and weight disorders, and pain management
(Riva et al.), it has yet to become widespread beyond the
research setting, with relatively little translation into the
ordinary clinical setting.12 Even if many technological bar-
riers have been overcome by the wide availability of
consumer-oriented VR solutions (see Table 1), many human
barriers remain.
 VR THERAPY: EMERGING TOPICS AND FUTURE CHALLENGES 5

gaze, a built-in
These are related, on one hand, to the concerns over per-

835 processor)

(rotation) and
head tracking

Medium (using
Snapdragon
ceived negative aspects of VR treatments and, on the other

None (internal

Medium/high:

backward)
2,560 · 1,440

positional

(forward/

pad, or a
Mirage Solo

Google Play
joystick)
tracking
hand, to the lack of specific clinical training in VR therapy.

U.S.$299
As underlined in a recent article by Linder et al.,13 even if

75 Hz
100
clinicians overall have a positive attitude toward VR therapy,
the biggest barrier toward adoption in their clinical practice
835 processor)

or controllers)
(rotation) and
head tracking
Snapdragon is their concerns, for example that treatment improvements
Standalone

None (internal

Medium/high:

backward)
High (using a
Oculus Quest

2,560 · 1,440

positional

Oculus Store
(forward/
tracking

joystick
would not translate into real-world improvements and pa-
U.S.$399

tients not experiencing the virtual environment as real en-

72 Hz
100
ough. Though many randomized trials have proven VR’s
efficacy and even long-term treatment gains, many clinicians

gaze, a built-in
821 processor)

are still reluctant.14–16

Medium (using
Snapdragon
None (internal

Medium: head
2,560 · 1,440

Oculus Store
(rotation)

pad, or a
Some of these concerns may be alleviated by VR training

joystick)
tracking
Oculus Go

U.S.$199

programs presenting available validated protocols and the

72 Hz

tools used to implement them. However, the number of VR

90

training programs including both the clinical side—the pre-

tracking (rotation)

tracking (forward/

sentation of clinical protocols targeting a specific disease—

Medium/high: head
PS4 (U.S.$299) or
Console based

and positional

Playstation Store
and the technical side—the technical skills and tools required
Google Daydream Playstation VR

controllers)
(U.S.$399)

joystick or
backward)

High (using a
1,920 · 1,080

to implement them—are still scarce. As new technologies are

Table 1. Comparison of Commercially Available VR Systems

PS4 Pro
Downloaded by Iowa State Univ from www.liebertpub.com at 01/17/19. For personal use only.

U.S.$299

implemented into undergraduate and graduate level training

120 Hz
100

programs, this problem may resolve over time.

In conclusion, we hope you will use these studies as in-
High-end Android

Depends from the

1,920 · 1,080)

spiration for your own explorations into how technology can

90 Hz minimum
(>U.S.$499)

Medium (using
Medium: head
(minimum
U.S.$69–149

transform psychology and healthcare at large.

(rotation)

Google Play
joystick)
tracking

gaze or
phone

phone

96

Author Disclosure Statement

phone (minimum
phone or iPhone

No competing financial interests exist.

Google Cardboard

Depends from the

Middle/High-end

Low (using gaze

or IOS Store
(>U.S.$299)

1,024 · 768)

or a button)
Mobile based

Medium: head

(rotation)

Google Play

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U.S.$10–50

Android

tracking
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Address correspondence to:
Prof. Dr. Brenda K. Wiederhold
The Virtual Reality Medical Center
6540 Lusk Boulevard, Ste. C115
San Diego, CA 92121
E-mail: b@vrphobia.eu