Virtual reality therapy

What it is

In virtual reality therapy, a person wears a headset and enters a computer-made world, such as a bus, a supermarket, a café or a shopping street. There they practise situations they find threatening in daily life.¹ It is used for people with psychosis who feel suspicious or anxious among others, or who avoid going out, and is given alongside usual care.^2,3

How it works

Many people with psychosis avoid social situations because of suspicion and anxiety.² Staying away, or taking precautions while in a situation, can keep a fear alive, because the person never gets to learn that the harm they fear does not happen.⁴ In virtual reality, the person can enter such situations step by step, drop the precautions and test what they fear.⁴ The scenes can be adjusted to the person, so that the difficulty rises gradually.⁵ In the trials, paranoia and avoidance fell as people used fewer of these precautions.^2,3

There are two main forms. In VR-CBT, a therapist guides each session. In gameChange, a virtual coach inside the headset guides the person, with support from a mental health worker.^2,5

History

Researchers in London first used virtual reality to study paranoid thinking in 2003. Some people had suspicious thoughts even about neutral computer-made characters.⁶ In 2016, a study in Oxford tested it as a treatment. Practising in virtual social scenes while dropping precautions reduced how strongly people believed their delusions, more than exposure to the scenes alone.⁴ In 2018, a trial at seven Dutch mental health centres tested VR-CBT, and in 2022 the gameChange trial in England tested an automated version.^2,3 Since 2023, NICE has allowed gameChange in the NHS for people with psychosis and severe avoidance, aged 16 and over, while more evidence is gathered.⁵

How well it works

In the Dutch trial, 116 people with a psychotic disorder and paranoid thoughts had 16 sessions of VR-CBT or stayed on a waiting list, both alongside usual care. After treatment, paranoia and anxiety in daily life were lower with VR-CBT, and the gains held at 6 months. The time people spent with others did not increase.²

A later trial in the Netherlands and Belgium compared VR-CBT with standard CBT for psychosis in 98 people. Paranoia fell with both. Right after treatment, it fell slightly more with VR-CBT; three months later, the difference was no longer clear.⁷

In the gameChange trial, 346 people with psychosis who found it hard to go out had about six sessions of automated VR therapy, or usual care alone. After 6 weeks, avoidance and distress in everyday situations were lower with VR therapy. The effect was small overall, and largest in people with severe avoidance, such as those who could not leave home alone.³

A review of 9 trials of different VR therapies found a moderate reduction in overall psychotic symptoms, but no clear effect on paranoia alone.⁸

Possible downsides

In the trial that compared VR-CBT with standard CBT, more people stopped VR-CBT early: 38 in 100, against 24 in 100.⁷ In the gameChange trial, serious adverse events were about as common as with usual care: 9 people had one with VR therapy, and 7 with usual care.³ In the Dutch trial, no adverse events were linked to the therapy.² NICE notes that more evidence is needed on side effects and on how long the benefits last.⁵

Format

In the Dutch trial, VR-CBT was 16 one-hour sessions, one to one with a therapist.² gameChange takes about 6 weekly sessions of 30 minutes. A mental health worker supports the person, in person or remotely, and this can be an assistant psychologist or a peer support worker rather than a qualified therapist.⁵

Contraindications and cautions

NICE allows gameChange in the NHS only for severe avoidance. For mild to moderate avoidance, it should be used only in research.⁵ Clinical experts advised NICE that it would not be offered instead of antipsychotic medicine.⁵

Alternatives

CBT for psychosis (opens in a new tab) works on the same fears without a headset, and reduced paranoia almost as much in the trial that compared the two. AVATAR therapy (opens in a new tab) uses a computer-made likeness of a distressing voice; a virtual-reality version was tested in Denmark.

What we don’t know yet

• How long the benefits last.⁵
• Who benefits most, beyond people with severe avoidance.
• Whether VR-CBT helps more than standard CBT in the longer term.