Virtual Reality in Psychotherapy

What is the future of psychotherapy? How will future changes impact on psychotherapy, psychologists, and our patients? Recently, a panel of 62 psychotherapy experts using Delphi methodology tried to answer these questions. According to their answers, only 18 out of the 38 therapeutic interventions analyzed were predicted to increase in the next decade. In particular, the use of VR and computerized therapies were ranked third and fifth, preceded only by homework assignments (first), relapse prevention (second), and problem solving techniques (fourth). On the other side, traditional psychotherapy interventions such as hypnosis (32nd), paradoxical interventions (33rd), or dream interpretation (35th) were predicted to drastically diminish.

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However, the possible impact of VR on psychotherapy could be even higher than the one offered by the new communication technologies. In fact, VR is at the same time a technology, a communication interface, and a compelling experience. Because VR could be part of the future of clinical psychology, it is critical to all psychotherapists that it should be defined broadly.

How is it possible to change a patient? Even if this question has many possible answers according to the specific psychotherapeutic approach, in general change comes through an intense focus on a particular instance or experience by exploring it as much as possible, the patient can relive all of the significant elements associated with it (i.e., conceptual, emotional, motivational, and behavioral) and make them available for a reorganization of his or her perspective.

Within this general model, we have the insight based approach of psychoanalysis, the schema reorganization goals of cognitive therapy, the functional analysis of behavioral activation, the interpersonal relationship focus of interpersonal therapy, or the enhancement of experience awareness in experiential therapies.

What are the differences between them? According to Safran and Greenberg, behind the specific therapeutic approach we can find two different models of change: bottom-up and top-down. Bottom-up processing begins with a specific emotional experience and leads eventually to change at the behavioral and conceptual level, whereas top-down change usually involves exploring and challenging tacit rules and beliefs that guide the processing of emotional experience and behavioral planning. These two models of change are focused on two different cognitive systems, one for information transmission (top-down) and one for conscious experience (bottom-up), both of which may process sensory input. The existence of two different cognitive systems is clearly shown by the dissociation between verbal knowledge and task performance: people learn to control dynamic systems without being able to specify the nature of the relations within the system, and they can sometimes describe the rules by which the system operates without being able to put them into practice.

Even if many therapeutic approaches are based on just one of the two change models, a therapist usually requires both. Some patients seem to operate primarily by means of top-down information processing, which may then prime the way for corrective emotional experiences. For others, the appropriate access point is the intensification of their emotional experience and their awareness of both it and related behaviors. Finally, different patients who initially engage therapeutic work only through top-down processing may be able, later in the therapy, to make use of bottom-up emotional processing. In this situation, a critical advantage can be provided by the sense of presence provided by VR.

Finally, VR can play an important role in psychotherapy as a particular form of supportive technique, contributing to the therapist–patient relationship as well as enhancing the therapeutic environment for the patient. Even if supportive techniques are more common in psychodynamic approaches, they are widely used in different treatments. In general, they are considered as supportive as the following techniques:

 Demonstration of support, acceptance, and affection toward the patient

 Emphasis on working together with the patient to achieve results

 Communication of a hopeful attitude that the goals will be achieved

 Respect of the patient’s defenses

 Focus on the patient’s strengths and acknowledgment of the growing ability of the patient to accomplish results without the therapist’s help Using VR, it is possible for the patient to manage successfully a problematic situation related to his or her disturbance. By creating a synthetic environment in which the patient is likely to feel more secure, VR may enable the patient to express thoughts and feelings that are otherwise too difficult to discuss, thereby increasing the degree of closeness between the patient and therapist. Using VR in this way, the patient is more likely not only to gain an awareness of his or her need to do something to create change but also to experience a greater sense of personal efficacy.