Health in a headset: Virtual reality therapy and how to avoid its legal and practical pitfalls

This article, written by attorney Madeline Hutchings, was originally published by the NHBR and can be found here.

Look up images of “virtual reality therapy,” and you will find pictures of people staring into the 3-D headsets you thought were just for gamers. But these users are not playing the latest iteration of Resident Evil.

Virtual reality therapy is a therapeutic modality that utilizes an immersive, virtual world, usually simulated by a headset. In VRT, the patient may be the only one using technology, with the provider typically in the room to guide the patient through the process.

The possibilities for VRT’s “virtual worlds” stretch the imagination. Virtual reality technologies can “transport” users to 360-degree simulations of scenes from around the world. Take a stationary bike ride through Patagonia, for example. VR technologies can also generate “augmented realities.” A camera-equipped headset regenerates a simulation of its surroundings, into which you can insert new, digitally-generated objects. (Picture sitting in your office, looking into goggles that show you that same office, but now Margaret Thatcher is there.) There is even VR technology that can be programmed to generate smells.

VRT has demonstrated effectiveness in treating both psychological and physical ailments.

Mental health providers utilize VRT as an adjunct when treating a wide range of challenges, from PTSD to eating disorders. Many clients cannot travel to in-person sessions, or they feel discomfort in being physically “seen” even over video (e.g., certain patients with Parkinson’s disease, other disorders affecting muscle control or mobility, social anxiety, agoraphobia, or depression). These clients may choose to attend therapy via an avatar. VRT is an occupational therapy modality for clients with autism and ADHD. Clients with anxiety utilize virtual paradises to aid the practice of mindfulness.

The list of potential applications is extensive, but one subset of VRT that stands out is virtual reality exposure therapy. Traditional “exposure therapy” takes two forms: Imaginal exposure occurs in the office of the therapist, who helps the client imagine and confront a feared object or situation, whereas in vivo exposure involves facing the feared stimuli in the real world.

Virtual reality exposure therapy is something in between. A client with a substance use disorder can virtually navigate an environment containing triggers for relapse. A veteran can drive a Humvee around a scene associated with traumatic events. VRET programs advertise access to virtual worlds capturing common phobic scenarios: A user may sit on the exam table in anticipation of receiving a shot, share a room with a spider, or face a crowded auditorium. VRET allows for graduated but realistic exposure to feared or traumatic stimuli in a safe and convenient environment.

VRT is an adjunctive treatment for a range of physical ailments. For patients undergoing wound care or other acute or chronic pain, VRT provides compelling distractions that are effective as adjunctive analgesics. VRT is used in neurological rehabilitation (e.g., to improve muscle control following a stroke or head injury) and to improve engagement in rehabilitation or exercise.

Despite its myriad potential benefits, VRT represents relatively uncharted territory that carries a bevy of legal, ethical, and clinical risks and possible drawbacks.

Practical considerations arise when combining VRT with telehealth, from poor internet connection to insufficient digital literacy. Providers are especially disempowered to provide assistance in an emergency, as they may not be able to see the patients or their surroundings. And providers cannot make any assumptions about clients’ physical locations, when it comes to practicing across state lines: If your client is outside the state of your licensure, you will not get a pass just because your avatars are the ones doing the talking.

VRT raises new concerns regarding privacy. The VR industry collects and analyzes data on headset users, such as eye movements, facial expressions, body movements, and geolocation, collectively composing a user’s “kinematic fingerprint” and giving clues about the user’s environment.

VRT carries risks of harm. It can result in “cybersickness,” a type of motion sickness characterized by nausea, disorientation, headaches, dizziness, fatigue, sweating, and eye strain.

Its immersive nature can be retraumatizing or exacerbate fear, paranoia, or psychosis. It can cause “depersonalization” (detachment from self, such as out-of-body awareness) or “derealization” (detachment from one’s environment), making what is real feel unreal.

VRT has the potential to create or exacerbate technology dependence. VR overuse can easily lead to depression and anxiety. The immersive nature of much VRT evokes Bradbury’s “four walls and the dream complete.” One cannot in good conscience prescribe a treatment that, while curing one ill, causes a potentially greater affliction in the form of technology addiction.

The critical risk of VRT, however, is to the provider-patient relationship. A strong therapeutic alliance is one of the most outcome-determinative facets of psychotherapy. This alliance depends on empathic responding, which is most effectively communicated through the paralinguistics and nonverbals of firsthand interaction. In non-psychiatric settings, also, relationships built on trust and empathy encourage patients to seek care and be open with their providers.

Providers can take several concrete steps to navigate risks associated with VRT.

To reduce risk of harm, screen patients for contraindications to VRT. Cybersickness is particularly likely for individuals prone to motion sickness or headaches, who have a history of vertigo, seizures, or stroke, or who have developmental disabilities or neuro-degenerative conditions. Technology dependence is more likely for patients with personal or family histories of substance misuse, behavioral addictions (e.g., gambling addiction), or impulsivity. Depersonalization and derealization is of particular concern among people with psychotic disorders, dementia, or other cognitive impairments associated with poor distinctions between real and false beliefs.

To keep VRT from weakening provider-patient relationships, remain vigilant that every use of VRT in a given appointment is intentional, measured, and not at the expense of trust and empathy.

Obtain meaningful informed consent specifically for VRT.

VRT carries unique risks regarding privacy, cybersickness, re-traumatization, and technology dependence, and its scope of use and limitations are different from other modalities. Recognize that, due to the modality’s nuances, some patients may not be able to understand VRT’s risks and therefore cannot provide valid informed consent.

Document your precautions. The patient-centered practices described here will enhance care, but they lose their risk management mileage if you have no evidence that you used them. Ensure that each decision to add VRT to a treatment plan is accompanied by documentation of an individualized assessment of patient needs, screening for contraindications, and a thorough informed consent process.

VRT involves charting unfamiliar terrain, even for the technologically savvy provider. The benefits may be great, but so may be the risks. So proceed with curiosity but also with care. Virtually anything is possible.