Can technology improve access to treatment?
It is estimated that one in six people experienced a common mental health problem in the last week, while mental health problems are reported to be the main drivers of disability worldwide, causing a cumulative 40 million years of ill health in 20 to 29 year olds. In the UK, the Department of Health has reported that mental ill health accounts for nearly 23% of the entire healthcare burden. Wider economic costs, including the direct costs of services, lost productivity at work and reduced quality of life, are estimated at £105 billion annually.
Even setting aside the costs, which are forecast to double over the next 20 years, there may not be enough trained mental health professionals to keep pace with the problem. Evidence suggests that the demand for private counselling services has increased by 65% since 2016, but private services are beyond the means of most. While the government has committed to training an additional 10,500 high-intensity therapists to provide NHS treatments by 2021 under the Improving Access to Psychological Therapies program, the ambitious-sounding targets will only provide access to 25% of people in need of treatment. And to compound matters, the stigma associated with mental health will continue to prevent millions from seeking in-person treatment. If we’re to avoid a full-blown mental health crisis, access to treatment needs to be scaled up massively. Can technology help bridge the gap?
Healing on the virtual battlefield
One day in 2014, Jimmy Castellanos woke up without having experienced a terrifying dream about his experiences on the battlefield in Iraq. A 13-week program of virtual reality therapy had sent the symptoms of his diagnosed post traumatic stress disorder into remission. As reported by NBC News, the process was not pleasant, but the results were life changing:
“In 13 weeks I’d completely changed who I had been for the previous ten years. Before the treatment, 80-90 percent of my dreams were Iraq related. Now I can’t remember the last time I had one. I live in a completely different way now.”
Post Traumatic Stress Disorder, or PTSD, is an anxiety disorder which, as well as causing feelings of isolation, guilt and irritability, makes people relive distressing events through nightmares and flashbacks. In Castellanos’ case, it was a mortar explosion during his first tour in Iraq in 2004, in which his friend and bunkmate was killed.
One of the most effective ways of treating PTSD is through Prolonged Exposure Therapy (PET), where patients are repeatedly asked to revisit their memories of the traumatic experience until it no longer triggers an anxiety response. Since the late 1990s, researchers have been experimenting with Virtual Reality simulations which reconstruct the traumatic events of war veterans to improve the effectiveness of exposure therapy. Today, the Bravemind application, which also makes use of weighted replica guns, a vibrotactile platform to replicate the sensations associated with explosions and firefights, and scent machines to add evocative aromas like diesel fuel and gunpowder, is used by governments around the world to rehabilitate serving and ex-service men and women with PTSD.
Taking therapy out of the clinic
But Post Traumatic Stress Disorder doesn’t just affect members of the armed forces. A 2010 study conducted by the European College of Neuropsychopharmacology (ECNP) indicated that 3% of the UK population suffers from PTSD. A company called SilVRmind is developing a VR-assisted treatment for the disorder based on eye movement desensitisation and reprocessing (EMDR) therapy, which is known to be effective.
In EMDR, the link between a traumatic memory and psychological stress is broken by having a patient track a moving object with their eyes as they recall the triggering event. The plan is to create an application which can be used without the direct supervision of a therapist. If we believe SilVRmind’s claims about the effectiveness of EMDR in the treatment of a range of other problems like depression, anxiety, phobias, panic, addictions, and unwanted emotions like anger, grief and low self-esteem, then VR has the potential to revolutionise the field of psychotherapy.
Even if we take those claims with a pinch of salt, there are already other kinds of virtual reality and augmented reality applications which are being used by clinicians to treat people with phobias and anxiety disorders. Mel Slater, designs virtual environments in the Department of Clinical Psychology at the University of Barcelona to treat a range of mental health problems. One of the pioneers of the use of VR in psychology in the 90s, he told the Guardian why it’s different this time:
“…for a long time people said, ‘It’s not going anywhere because it’s too expensive.’ The equipment we used at UCL cost £1m. The equipment I have in Barcelona, when I set up there 10 years ago, was £100,000. Now I can do the same thing with £3,000.”
And he explains how virtual reality can, in many cases, be more effective than therapy that’s restricted to the real world, because it allows people to take risks that they never would in real life:
“I was in one session where the guy had such a fear of public speaking that he told us about speaking at his daughter’s wedding, and we said, ‘How old is your daughter?’ and he said, ‘Three!’ So he spoke to a virtual audience. He said: ‘I can’t do this, I’m turning bright red, my voice is an octave higher.’ The psychologist later played it back to him and said: ‘Is your face red? No. Are you speaking an octave higher than normal? No.’ The psychologist did in one afternoon what would normally take 12 weeks.”
Last year, startup Oxford VR announced that it had raised £3.2 million in investment after conducting a trial of VR therapy for acrophobia (the fear of heights) with 100 people who reported that the severity of their symptoms decreased by an average of 68 per cent following treatment. The company’s approach is designed to work without the intervention of a human therapist. Instead, cognitive behavioural therapy is delivered alongside the VR experience by a virtual therapist. Staffed by VR experts from the world of gaming, the company is planning to design therapies for social anxiety and psychosis next.
Almost at the same time as the Oxford VR announcement, biomedical engineering researchers and software engineers in Germany were showing off an augmented reality application for treating arachnophobia at the MEDICA trade fair in Düsseldorf. Their solution incorporates a biofeedback mechanism “which consists of wearable sensors that measure the patient’s vital parameters during a session, such as their heart rate variability, skin conductance and breathing rate” to monitor people’s reactions to performing tasks like prodding a simulated spider, or the well-known glass-and-postcard capture maneuver. While the price of AR headsets alone means this kind of experience isn’t bound for home use anytime soon, there are augmented reality smartphone apps already on the market which try to offer similar experiences. One, Itsy, has been reviewed and endorsed by NHS England.
Virtual reality, real wellbeing
Because this is VR’s second lap of the hype merry go round, it’s picked up more than its fair share of skeptics. Antti Oulasvirta from Aalto University’s User Interfaces research group just last week published a Tweetstorm setting out nine reasons why current virtual reality technology hasn’t seen a killer app. Most of them focused on the difficulty of creating a workable user interface with VR for interacting with programmed content – holding up your arms for extended periods is painful, motion tracking of hands and objects is poor, mid-air gestures provide no feedback and aren’t efficient for text entry. Reasonable objections if you expect VR and AR to take over the functions of smartphones and desktop computers, but what if the virtual-reality killer apps don’t require the user to do anything at all? What if VR’s most revolutionary potential is as a delivery vehicle for applications where content is consumed passively, like an immersive movie? Or even ones where the interface is not between the device and some external part of the user’s anatomy, but between the device and the interior of the user’s body?
Meditation is one of the fastest growing health trends in the Western world. Analysis of the National Health Interview Survey suggests that the portion of adults engaged in meditative practice rose from 4% of the US population in 2012 to 14% in 2017. Among children, the increase was even more pronounced, from 0.6% in 2012 to 5.4% in 2017. People are being drawn to practices like mindfulness meditation, Zen Buddhist meditation and transcendental meditation for many reasons, including reducing stress and improving mental health and wellbeing. The recent explosion in meditation apps for smartphones, including Headspace which claims over 31 million users, testifies both to this trend and to the growing appetite for technologies which both help people begin meditating and then help them meditate more effectively.
While there are a number of apps for VR devices which offer guided meditations in serene virtual environments, DEEP-VR is one of the most innovative in its use of biofeedback. The game’s custom controller is a band that wraps around the user’s abdomen to measure diaphragm expansion and sense the user’s breathing patterns. As the player navigates a tranquil underwater world, the game encourages them towards yogic breathing techniques to foster deep relaxation and combat stress and anxiety. Developed in conjunction with the Behavioural Science Institute at Radboud University in Nijmegen, the Netherlands, the game has shown potential as an intervention for anxiety in children as well as for calming stressed video game journalists. Other similar games use heart-rate monitoring via a smart watch or chest strap to guide users into a meditative state.
What’s missing from the technology so far available is direct biofeedback from the organ most involved in mental health processes: the brain. But researchers at Imperial College London are working on a system, Dream Machine, which measures users’ brainwaves with electrodes embedded in the VR headset. The VR experience is then gamified so that greater levels of meditative concentration results in more aesthetically-pleasing content for the user. Dream Machine’s inventor, Dr Jamil El-Imad, told Culture Trip that such systems could open up immense new possibilities for mental health treatments:
“We don’t truly understand how the brain works, but until now the focus has been on pharmaceutical treatments. Going forward, I think it’s important to look seriously into science-based, non-pharmaceutical alternatives. The Dream Machine was built around the idea of neuroplasticity – the fact that we aren’t hard-wired, and experiences can change the way our brains process and deal with experiences.”
Indeed, academic studies have provided evidence that not only can immersive VR experiences be effective aids in treatments for anxiety disorders, but also that it can be used to help in the management of both acute and chronic pain. This is an important potential application of VR, given that the overprescription of pain medication has contributed significantly to the opioid crisis in the US, and of an emerging similar trend in the UK.
Mental health care from the inside out
It seems that in the field of mental health and wellbeing, the convergence of technologies including augmented and virtual reality, advanced biometrics and artificial intelligence powered by machine learning has the potential to take over the roles of doctor, pharmacist, therapist and guru. A brave new world of highly-targeted, self-administered mental health treatments that dynamically respond to accurate biometric data could be just over the horizon.
Exploration into the use of AI as a diagnostic tool is already receiving massive amounts of funding from both established healthcare companies and new entrants from the tech world, including Alphabet, Microsoft and Amazon. Meanwhile, wearable biosensors are already being used to track the variation of heart rate, activity, skin temperature and other variables to pick up on infections and other illnesses before their victims start to present visible symptoms. In time, sensors which wirelessly transmit hundreds of such variables could be contained within tiny medical implants deployed to regions of interest around the body.
Imagine going about your daily life as microscopic sensors beneath your skin continuously send data about your various biological functions and states back to cloud-based medical services which, empowered by machine learning and vast troves of data from millions of other people around the world, compares your vital signs against known ailments and mental health issues, before deciding that you are in the early stages of the onset of depression. It then picks out a targeted, tailored intervention which another AI guides you through, monitoring its effectiveness using real-time data from your implants. Of course, you wouldn’t be conscious of any of this background activity. You might just feel a bit under the weather, receive a notification telling you that a new guided VR meditation, tailored just for you, has been delivered to your device. After completing the guided meditation from your personal, virtual therapist, you feel a bit better, and carry on with your day.
Such an approach to the treatment of mental health problems, if made available to enough people, might be hugely effective at combating the emerging crisis, but enthusiasm should be tempered by at least two major caveats. The first is that such services have to be designed with the help of medical experts, be based upon peer-reviewed science and be tested via rigorous clinical trials. Many of the claims made by apps currently on the market are unsupported by evidence and, when they fail to deliver the promised results, could further increase the distress of people with serious mental health problems. The second is that this approach involves handing over personal data of an intensely intimate nature to distant service providers in volumes orders of magnitude higher than we already do. Fears of algorithms that can predict our behaviour better than we can, and the chilling effect that such predictive power could have on free expression, are well grounded. Do we really want to invite these algorithms inside our bodies?
In Brave New World, Aldous Huxley describes a society where advanced medical technology – reproductive, psychological and pharmacological – has rendered negative feelings and behaviours almost obsolete thanks to the prescription of the drug soma whenever such feelings arise. Soma fills everyone with “the inner light of universal benevolence”, but it also precludes the possibility of any resistance to a system of social control that is intensely hierarchical, homogenous, predictable and conformist. After taking it, people enter “the warm, the richly coloured, the infinitely friendly world of soma-holiday. How kind, how good-looking, how delightfully amusing every one was!”
Vigilance will be required to guard against the possibility of our digitally-generated virtual worlds becoming our own soma.
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This article also appears on The Panoply Future Thinking Blog.