Exposure and response prevention (ERP) therapy is the gold standard for treating obsessive-compulsive disorder (OCD). Developed in the 1970s, the technique has proven to be highly effective and remains the first line of treatment for all forms of OCD.
Because of how well ERP works, the way it is delivered has remained relatively constant over the last half century, which is typically in-person, in an office with a therapist. Thanks to more modern technologies, we now have virtual ERP therapy via live video sessions, which has been shown to be as effective, or even more so, than traditional in-person ERP. Recent technologies, particularly virtual reality (VR) headsets, have the potential to provide even further advancement in ERP therapy. Offering users the ability to enter immersive, interactive worlds, researchers have been investigating whether this tool might prove helpful as an alternative way to generate exposures in the ERP process. The results they’ve found are promising.
We scoured the internet for the latest research and talked with our in-house expert, Dr. Patrick B. McGrath, Chief Clinical Officer here at NOCD, who has professional experience using VR for ERP therapy, to shed light on how VR might enhance treatment for OCD. In particular, this article will cover the following topics.
- What is ERP?
- What is VR?
- Why VR might enhance ERP
- What recent studies say
- What are VR’s limitations?
- The future of Virtual Reality ERP (VRERP) for OCD
What is ERP?
ERP is a therapeutic technique that interrupts the OCD cycle by addressing the compulsions people engage in after experiencing obsessions, or intrusive thoughts, images, or urges that cause distress. Though these compulsions provide temporary relief, they increase the frequency of obsessions over time, increase the intensity of the distress and anxiety, and strengthen the urge to engage in further compulsions.
To free people from this vicious cycle, ERP helps patients trigger obsessions in a controlled environment while resisting the urge to engage in compulsions to provide temporary relief, beginning with what is least stressful or anxiety-inducing. Over time, this reduces the frequency of obsessions, reduces the negative emotions they cause, helps people sit with uncertainty, and teaches them they can handle anxiety rather than avoiding it at all costs.
Two main types of exposures
For most of ERP’s existence, it has relied on two types of exposures: imaginal and in-vivo. Each type has its particular applications and benefits, depending on the situation.
As the name suggests, imaginal exposures involve imagining, thinking about, or bringing to mind a person’s obsessions or feared situations. Consider Relationship OCD (ROCD); someone with this OCD subtype may write exposure scripts about never feeling sure if they have the “right” feeling for their partner or if they’d be better off with someone else.
Imaginal exposures have several benefits. For one, they often cause less distress than real-life exposures, so they are helpful earlier in the ERP process for obsessions that cause a significant degree of anxiety. They also work well for obsessions for which there is no reliable way to physically encounter a feared idea or situation.
In vivo (real-life) exposures
During in-vivo exposures, people physically encounter feared situations or triggers in real life. For example, someone with Contamination OCD, after progressing through less direct exposures, may be asked to physically touch objects that they typically deem “dirty.” Though this type of exposure can also be more impactful, it can feel overwhelming without the proper care and planning. Additionally, it’s not always feasible to create direct physical exposures for someone’s obsessions, like those that involve past events.
How might VR enhance or supplement ERP?
Virtual reality refers to any computer-generated three-dimensional simulation of reality designed to generate immersive and sometimes interactive experiences.
Over the past few years, VR technology, particularly VR headsets or head-mounted displays (HMDs), have become increasingly powerful, affordable, and easier to use, leading to a significant rise in the adoption of VR for activities like gaming or other forms of entertainment.
Though VR is often used just for fun, mental health experts have wondered whether it might be helpful as a treatment for mental health conditions, particularly as a tool for practicing exposures in ERP.
But are there any reasons to think that VR could make ERP better than it already is? Here are a few reasons for further interest, depending on the situation.
#1 Our ability to imagine situations differs
For imagination-based exposure to work, you must be able to imagine the scenarios in question. Moreover, how vividly you can do this can impact the treatment’s effectiveness. The problem is that not everyone is equally good at imagining things—this ability varies widely from one person to another.
In addition, because imagination-based exercises can still be stressful, some patients may have trouble getting themselves to call to mind the relevant experiences, even though they typically have good imaginative abilities. As a result, VRERP may prove beneficial for those with weaker imaginative abilities or who have trouble getting themselves to imagine the intended experiences because it is particularly stressful.
#2: VR is incredibly immersive
If you’ve ever used VR or watched someone try it out, you might have a sense of how immersive it can be. The result is that VR can make one feel like they are in a new world with actual events, giving it a possible advantage over imaginal exposures. Dr. McGrath notes, “In imaginal exposure, you can be limited by the imagination of the member or the therapist, but in the VR work, you can make things amazingly life-like and realistic.”
#3: The level of detail and immersion is adjustable
Though VR can offer incredibly life-life experiences, the level of detail can be adjusted, and VR generally doesn’t replicate other aspects of physical experiences, such as tactile sensations (though there is work being done in this area). As a result, VRERP can offer a middle ground between imaginal and in-person exposures. For those working their way through ERP, this type of exposure might allow them to approach real-life fears and triggers without overwhelming them.
#4: Some exposures are difficult to carry out in real life
While exposures for some OCD subtypes, like contamination, may be relatively straightforward, others can be a little more complex due to cost, logistics, or ethical considerations. Dr. McGrath shares his experiences creating exposures for symptoms related to Harm OCD—more specifically, fears about harming others while driving, where VR might have proven useful.
“As a therapist, what I used to do is go out into parking lots with people and have them drive around the parking lot as I walked right next to them,” he shares. But this type of exposure isn’t always doable without VR. “If I’m with someone and they’re driving their car, that’s one thing, but my insurance doesn’t cover other people driving if I’m using my car for work, so if they can’t bring their car, the exposure can’t be completed. VR could solve that sort of situation and allow for more creative exposures.”
#5: VR provides an additional sense of safety
Even though exposures are designed to ensure patients are safe, it may not always feel that way to those going through the process. While this may still be the case for some people engaging in VRERP, it’s less likely, as users understand to some degree that the experiences are not real and cannot harm them.
What do the studies show?
In theory, VRERP is promising for several reasons, but what has research shown? Does VRERP work, and how does it compare to the other types of exposures?
Several studies have found VRERP effective. However, the data is limited by the subtypes or themes of OCD that have been studied. In particular, researchers seem to have focused exclusively on contamination OCD. In these experiments, participants wear VR headsets while viewing and interacting with various “contaminated” objects in different environments without engaging in compulsions. Results have consistently found VRERP produces significant reductions in contamination OCD symptoms, with some reporting the results are comparable to in-vivo exposures.
Notably, some have also found they could consistently adjust how anxiety-inducing the scenarios were, by modifying aspects of the virtual environment, like how “dirty” it was. This suggests it may be easier to fine-tune exposures so that patients can more gradually work their way up their exposure hierarchies.
Going beyond the literature on OCD, studies have found that VR can treat a wide range of phobias. Dr. McGrath has personal experience using VR for social phobias, substance abuse disorder, and post-traumatic stress disorder (PTSD), indicating that VR’s use can be effective for more than only contamination-related fears.
What are VR’s limitations?
Though VRERP appears to be a promising way to supplement standard ERP, it has its limitations. To start, devices are still somewhat costly, and treatment centers with a stock of VR headsets are rare.
Second, though treatments are customizable, developing a new VR exposure experience is no simple feat. “You need money, time, and effort to build new simulations set up for the fears and obsessions of particular patients,’ shares Dr. McGrath. “But that will probably change over time, with accessible virtual exposure libraries for therapists to use.”
A similar concern is that for OCD treatment, VRERP has primarily been studied using exposures for Contamination OCD—whether it is feasible and effective for other OCD subtypes remains to be studied in formal settings.
What’s next for VRERP?
With all that in mind, one might wonder what happens next—where might the technology go from here?
At least three key things may change in coming years that could impact how promising and feasible VRERP is as a common treatment for OCD. The first is that as more people purchase VR devices and production increases, the cost may drop, making it more affordable for therapists and treatment centers to incorporate VR into ERP.
Second, as mental health awareness continues to grow, along with knowledge of VR’s capabilities, developers may create powerful mental health apps. Many already exist for other treatments, such as meditation and mindfulness, and even for specific phobias. Dr. McGrath is optimistic about the expansion of these tools in the future. He states, “I think over time, we’ll have more libraries of virtual exposures that mental health professionals can utilize.”
Virtual reality devices can improve in several ways as well. For example, the graphics may become more realistic, offering more accurate visual experiences. Second, VR may incorporate other technologies like haptic feedback to simulate touch and other senses. This will enable VR headsets to deliver more immersive experiences, which could mean more impactful exposures.
Ultimately, VR may radically shape how we carry out the ERP process. “The hope here is that in the next 10 years, you’ll see VR play a major role in all kinds of exposure therapies,” says Dr. McGrath. “I really do feel that it will be huge.”