The Virtual Couch: Rise of the digital therapist

Moves are being made to add an online cognitive behavioural therapy (CBT) service to Scotland’s NHS 24 portal. It is even possible to get an app, Health By Mindstrong, for your phone that, it has been claimed, tells you if you’re depressed before you know it yourself.

But isn’t therapy something that needs a human connection? And does this mean the robots are set to steal yet another sector of human jobs?

Among those pioneering this digital field is Professor Daniel Freeman of Oxford VR, a clinical psychologist who has developed a range of VR treatments for anxiety disorders, including one which has been shown to reduce anxiety around heights by, on average, two-thirds.

Put the headset on, and you enter a world in which, accompanied by an avatar therapist, you are encouraged to walk over a rope bridge high above some palm trees in what looks like a luxury mall. Oxford VR filmed before-and-after footage of users of this simulation navigating heights, showing how a three-hour session can help.

In one film, a woman who previously couldn’t get on a high escalator steps out easily on to its moving platform, saying, “It’s fine. I can do it." She laughs, perplexed. "It’s really really weird.”

But, says Freeman, who is appearing at a Digital Therapist event at the Edinburgh Science Festival today, VR isn’t just capable of helping us with what seem like more straightforward phobias and anxiety-disorders. It can also help with depression, schizophrenia, paranoia.

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Recent decades have seen a phenomenal rise in mental health awareness and the reporting of mental health issues, if not their actual incidence. The end of 2018 saw the worst waiting times statistics for child and adolescent mental health on record in Scotland.

The number of university students in Scotland seeking support for mental health issues has increased by two-thirds over five years. One of the big questions of our time is how to meet the challenge of providing adequate mental health services on current, reduced, or even increased, budgets.

Freeman believes VR provides part of the answer. “Many of us clinical psychologists are aware that there are some really good treatments available if you see the right therapist doing the right treatment, but we need many more people to get these treatments. How do we help all the people who need help? I think one key part of the solution is potentially virtual reality.”

The idea of VR therapy isn’t entirely new. The United States military pioneered what has been called Virtual Reality Exposure Therapy in the treatment of PTSD among veterans. But usually such treatments have been delivered by, or in conjunction, with a human therapist.

What distinguishes Freeman’s treatments is that the therapist is embedded within the simulation, as an avatar. “You don’t need to find that right therapist,” says Freeman, adding: "I think that’s incredibly exciting and I think actually it is one of the ways to help the very large numbers of people.”

Freeman has been trialling such simulations to help people deal with a range of problems, from height anxiety through to more complex mental health problems like schizophrenia and paranoia. “What we’re doing is helping people with schizophrenia who have withdrawn from life, who are staying inside because they’re anxious to be around other people. We’ve designed a new treatment that helps them practice going into situations in VR, to learn that nothing bad is going to happen to them. And they actually gain confidence to then do it in the real world.”

In fact, Freeman first began using VR in 2001 when he was working on paranoia. He found it could be used as an assessment tool to judge whether people really had paranoia. Then, in 2016, when the Oculus Rift was launched, he had a lightbulb moment. “I suddenly thought this is really accessible VR kit, and if you then automate the treatment this could be amazing, this could really change things.”

Are there limits to what VR could treat? “There are very few conditions that wouldn’t suit a VR treatment,” says Freeman. “There is a very simple reason for that, which is that mental health problems are completely bound up with the environment. If you have a problem with alcohol then being around alcohol is difficult. If it’s social phobia, it’s being around people. Mental problems play out in day-to-day environments and what’s brilliant about VR is that you can produce computer simulations of environment and through the simulations coach a person in how to think, behave and feel differently.”

The VR headset, in other words, allows you to be the equivalent of a pilot training to fly on a simulator. “People are more likely to act differently and try new things out in a computer simulation – and that gets them to do stuff that they would find very hard to change in the real world. If you change it in VR it does change in the real world.” Freeman says he thinks it’s “actually faster than face-to-face therapy and a lot more engaging”.

He believes it is important to test such treatments in clinical trials. “VR is not an answer in itself. The content matters hugely and you could produce a VR treatment for a condition that doesn’t work. We run randomised controlled trials. They’re a lot of work. They’re expensive. But they’re vital.”

Though Freeman believes in the technology, he is also keen to make clear that it is not designed to replace the human therapist. “I think we actually need more therapists, not fewer. For some issues and for some people’s preferences they need to see a therapist, and we need more of them. But I think if we’re going to reach the large numbers of people we need to help, then VR needs to be one part of the equation.”

But you don’t have to even have access to a VR headset to use some of the digital therapeutic programmes available now – all you need is the smartphone in your pocket. Mental health apps, which range from mindfulness programmes through to CBT and other therapeutic methods, are booming. They are set to include, for instance, Alli-chat, an app in development by hotly-tipped Scottish tech company, Voxsio, which aims, through AI-driven conversation to “help young people understand their mental health and encourage them to continue to talk, both with Alli and also their support network”.

Dr Sheila Ross, an Edinburgh-based therapist who was involved in the creation of an app that has been endorsed by the NHS called Feeling Good: Positive Mindset, believes phones are an ideal means for delivering a mental wellbeing programme. “The thing about phones is people carry them around. Once you’ve got the app on your phone it’s there. You don’t need an internet connection. And with Feeling Good you’re just listening so it’s not like you’re having to deal with the screen.”

Like Freeman, Ross doesn’t see this app as replacing the therapist. In fact, she sees it as running alongside. “One of the drivers for this is that 20 years ago I had a period of low mood or depression. I remember going to the counsellor and at the end of that session, they said, ‘Well come back next week.’ I remember that feeling of what am I meant to do for the week in between? This helps people learn how to help themselves – to learn the techniques to build up their own mental resilience.”

The Feeling Good app was in fact inspired by a Swedish programme, called Integrated Mental Training, which was designed by a sports psychologist and Olympics trainer. Ross and her colleague GP Alastair Dobbin had come up with the idea of making something similar for the health service, which could be use by primary care providers themselves and their patients. “Coming from sports,” she says, “it’s all positive psychology and it doesn’t have any stigma whatsoever, so it’s very very accessible.”

Ross points out that a key element in the Feeling Good downloads is visualisation. Just as with the VR, you are practising, in your imagination, what it would be like to feel better or react to a situation better. “One of the things that helps people recover,” says Ross,” is your ability to see yourself recovered in the future. It’s about people visualising themselves feeling better. That’s the link with athletes. Athletes visualise their athletic performance. Depressed people visualise themselves being better. And when you’re better you’re more sociable and outgoing. So although it’s not a virtual reality headset, people are creating it in their minds.”

An example she gives from sport is the free climber, Alex Honnold, who climbed El Capitan, solo and without ropes. “Honnold said,” says Ross, “that how he prepared was visualisation. He visualised every single handhold, and also how it would feel in his body. That’s what we need to do, to help ourselves perform well – visualise.”

But does therapy delivered on a digital platform work? In 2015 the effectiveness of computer-based CBT was called into question after a study published in the BMJ reported that it had found that patient adherence and engagement was low. “Participants offered CBT,” the report said, “were generally unwilling to engage with computer programs and highlighted the difficulty in repeatedly logging on to computer systems when they are clinically depressed.”

Since then, however, digital therapy has evolved, as has the technology and our relationship to it. The platform for digital therapy has shifted, to these more accessible apps on our phones. Earlier this year, NICE, which provides guidelines for the NHS in England, endorsed the use of smartphone apps for the treatment of mild depression in children as young as five

Feeling Good is one of 19 mental health apps that are endorsed by the NHS and available through its library. Among the twelve is Big White Wall, which provides an online mental health community. CEO, Henry Jones, recently wrote a column in The Herald, making the case for technology as the solution to the mental health crisis in the young, and arguing that “it provides the opportunity for 24/7 access to early intervention and prevention support, helping the masses with lower levels of distress by providing a clinically safe and moderated online community”. He added that this “then frees capacity for those with higher need, who require specialist and more intense treatment.”

Frequently that is the big message of the digital therapy creators and providers – that they are delivering an answer to our mental health crisis which can't practically be met by therapists. Sheila Ross, for instance, says that for her it was “100 percent” about dealing with the issue of how to deliver cost-effective mental wellbeing. ” Anxiety and depression are normal within us, what we have to learn is how to keep it within a manageable range so we don’t get the extremes.”

Digital Therapist is at the Edinburgh Science Festival at 8pm today, April 14