“The effectiveness of virtual reality exposure therapy is important because social anxiety disorder is vastly undertreated,” says Dr. Page Anderson.
We humans are deeply social creatures. We live our lives in the company of others: we work together, eat together, play together, and sleep together. Yet, for some of us, interacting with other people can really be “hell.” The prospect of talking with a stranger, ordering food in a restaurant, or speaking up in a work meeting, can, for some people, be an incredibly daunting and fear-provoking experience. This is very much the case for sufferers of “social anxiety disorder.”
Social anxiety is the intense fear of being negatively evaluated or judged in social situations. While it is not uncommon to feel nervous in certain social settings (think first date or giving a presentation), sufferers of social anxiety disorder experience this fear to such an extreme and excessive degree that they tend to avoid opportunities to socialize. Sufferers may find themselves avoiding job interviews, missing out on opportunities for promotion, and, in some severe cases, avoid public spaces altogether. As many as 15 million Americans suffer from social anxiety disorder, yet, only one-third of sufferers receive treatment. Seeking treatment can be difficult as doing so requires sufferers to interact with strangers — the kind of interpersonal experience that many sufferers are prone to avoiding.
Social anxiety is typically treated using a combination of cognitive behavioral therapy and exposure therapy. Under the guidance of a psychologist, patients are initially supported in facing their fears by imagining the fear-provoking setting, and later, by encountering the setting in real life, while accompanied by their therapist. One of the challenges of this kind of therapy is that exposing patients to fears in the real world involves unpredictability and uncertainty, where things can go awry, risking reinforcing a patient’s fear. In light of this, some psychologists are now embracing virtual reality technologies, which are offering a new form of exposure therapy to patients, an approach with very promising results.
At the Virtual Reality Medical Center in La Jolla, California, executive director and clinical health psychologist Dr. Brenda Wiederhold specializes in treating social anxiety disorder with the use of virtual reality exposure therapy. For over 20 years, Wiederhold has used various forms of virtual reality technology to help patients cope with the public-speaking demands of a new job, adjust to major life transitions (like going away to college), and enter new and challenging social environments. For Wiederhold, virtual reality creates a benign setting in which the feared social scenario can be controlled, and the patient’s responses can be carefully monitored, in a safe environment.
As with traditional cognitive behavioral therapy, Wiederhold’s treatment begins by teaching patients to recognize their bodily signals of anxiety, and then helps them to reframe the automatic thoughts they experience when encountering their feared situation. Once a patient has made progress with these skills, they can begin practicing in virtual social environments. Under Wiederhold’s careful supervision, patients wear virtual reality headsets and enter a virtual representation of the scenario they fear the most — be it talking in a boardroom meeting, presenting to an auditorium full of people, ordering a meal at a restaurant, or stopping a stranger on the street to ask for the time.
These virtual settings are populated with avatars that act and respond dynamically, almost like real people. As patients become more familiar with their virtual setting, Wiederhold is then able to adjust and ramp up the stressors in the controlled environment, giving patients an opportunity to practice their most feared worst case scenarios — for instance, by imitating restless, bored, or disruptive co-workers, or uninterested audience members, the patient is given a chance to build up a sense of control in these otherwise erratic settings. As such, patients are able to experience being in their feared situation, and coping through it, in the presence and safety of a therapist. Thanks to this controlled exposure, patients are then better equipped to face their fears in the real world.
Wiederhold has an extremely high success rate, with 92 percent of her patients showing considerable improvement in their social anxiety, leaving therapy displaying less avoidant behavior. Yet, according to Wiederhold, virtual reality exposure therapy does not work for everyone. “There is a small subset of people for whom virtual reality therapy does not work because they cannot become immersed in the setting,” says Wiederhold. “To be effective, patients have to suspend disbelief, let go of control, and give themselves permission to enter into the world.”
Perhaps surprisingly, immersion in the virtual world does not depend too heavily on the virtual world being an exact replica of the real world. As Wiederhold explains: “The very first virtual reality settings I used were crudely animated, and I did not think they would work. However, even crude animation is helpful for my clients.” For Wiederhold, it is about featuring the right cues. With social anxiety disorder, patients are very aware of other people’s eyes, gestures, and emotions, so it’s a matter of making the eyes very visible, with good and clear hand gestures. When presented with the right cues, patients’ brains then fill in the rest of the fear-provoking details, and the situation feels remarkably real. By facing their fears in a virtual world, patients are then one step closer to facing their fears in the real world.
The clinical successes of virtual reality exposure therapy have been underscored by growing empirical evidence. In a study, Dr. Page Anderson, associate professor from the department of psychology at Georgia State University, and colleagues conducted a randomized controlled trial of virtual reality exposure therapy in treating social anxiety disorder. There were 97 participants in the study. Each participant suffered from social anxiety disorder and a fear of public speaking. Anderson found that participants randomly allocated to virtual reality exposure therapy experienced improvement in their symptoms, and were less avoidant in public speaking contexts. Even after a one-year follow-up, participants’ improvements had been sustained.
According to Anderson: “The effectiveness of virtual reality exposure therapy is important because social anxiety disorder is vastly undertreated, especially among young adults, and is associated with being less likely to go to college, gaining employment, and remaining in employment.” Virtual reality technology not only offers therapists more control of the social setting, but also allows patients to benefit from safe, repeated exposure to feared situations. “In the real world, if you put yourself out there, and face your fear, you try to get through it as quickly as possible and it is not therapeutic. In a virtual reality environment, patients can repeat the experience until they feel they have mastery over it.”
In explaining how this virtual reality exposure therapy works, Anderson highlights recent psychological and neurological theories of how fear works: “Fear memories do not just fade away. Instead you have to develop competing memories, by giving yourself new experiences of whatever you fear. By doing this, the brain pathways that tell you to avoid something become less strong relative to the pathways that tell you to approach something. It is a matter of learning to inhibit your avoidance response.” The brain regions involved in fear responses are the limbic system, specifically the amygdala and hippocampus, and the prefrontal cortex.
“The prefrontal cortex is where your decision-making is happening. With exposure therapy, the idea is, you improve the ability of your prefrontal cortex to inhibit or override the powerful fear response of the more primal and instinctive limbic system,” says Anderson. Virtual reality exposure therapy gives patients the opportunity to form new, less fearful memories of their feared situations, which overtime can lead patients to override their avoidance tendencies.
Having found strong evidence in support of the efficacy of virtual reality exposure therapy, Anderson’s next venture is to develop and test self-administered, online treatment for social anxiety disorder that allows patients to be treated from home. In the future, it may well be possible for sufferers of social anxiety disorder to more easily overcome their initial aversion to seeking treatment in person, and to begin the daunting process of facing their fears alone.
This article was originally published in the Spring 2017 issue of Brain World Magazine.