“Three men are constantly speaking to me behind my right ear,” says Pia Oxenvad, a young woman experiencing auditory hallucinations. “It feels like they are standing right behind me,” she explains, while indicating with her right hand precisely where the voices seem to be lurking. To Pia, the voices are real, an experiential and always proximate presence. Yet, to everybody else, the voices are unreal, a conjuring of Pia’s disturbed mind. Although Pia can hear the voices, she cannot see the men whose voices she hears. However, when she enters the realm of virtual reality (VR), Pia can both see and speak to the malevolent voices, which now present as avatars. These digital representations externalize her internal malady, moving the voices from the concealed and personal space of her mind to the visible and shared space of VR. To get to the realm of VR, Pia places a pair of sleek, yet clunky, goggles over her eyes, transporting her into a digitally designed, simulated environment. The goggles engulf Pia’s vision, fundamentally altering her sense of place. Although seated on a chair, at a table, in a room, Pia is tricked into believing that she is somewhere completely different, moved from the physical here to the simulated there in an instant. As she is immersed into the carefully curated space of VR, Pia and her therapist are enabled to confront Pia’s voices together for the first time.
This scene with Pia illustrates the vanguard of technologically mediated psychiatric treatment: an uncharted therapeutic territory that enacts a profoundly altered space of interaction that proponents hope will change the future of psychiatric therapy. Although clinical professionals gain new possibilities for creating standardized and near-natural environments for therapy, they also face new forms of uncertainty as the boundaries between the real and the unreal become open to interpretation. New modes of treatment also emerge, just as the roles of, and relations between, patients and clinicians become reconfigured. Even where treatment takes place is taken into question. According to early VR pioneer, Jaron Lanier (2017, p. 1), VR is indeed a “means for creating comprehensive illusions that you are in a different place.” But what does it mean that illusions take on reality? What is the epistemic significance of place in VR? And how do clinical professionals understand, produce knowledge about, and navigate the unreal during psychiatric treatment? As the therapeutic use of VR constitutes the frontier within digital psychiatry, it is vital that we try to understand the implications of its therapeutic use through both empirical investigation and theoretical conceptualization. I am currently working on funding applications to do just that, and I am therefore at the early stages of grappling with all the questions raised above. In this short piece, I share some of my preliminary reflections on the use of virtual reality in psychiatric treatment.
Virtual reality in psychiatric treatment
With the spread of digitalization, the places of psychiatric treatment are fundamentally changing. Among other reasons, this is due to the rising uptake of immersive technologies like VR, a key innovation in the continuously expanding landscape of digital mental healthcare. VR displaces treatment from the physical space of the clinic to the virtual environment of a head mounted display (HMD). On a general level, the main purpose of most VR systems is to perceptually replace the outside world with a virtual world, engaging users through a digital interface designed to create specific experiences. As such, VR both manipulates the psychological mechanisms involved in producing experiences of realness and codifies the therapeutic space, turning psychological phenomena into objects for technological intervention. Although VR is increasingly used in mental health research and is promoted as having the potential to change clinical practices, being “a psychologist’s dream,” as leading VR clinician Albert Rizzo contends, scholars continue to argue that the evidence-base necessary to justify the hype surrounding the technology still remains to be provided (Bell et al., 2020). Nevertheless, VR has been declared a new paradigm in clinical psychiatric care and is considered a serious therapeutic tool in contemporary treatment. In Denmark, where I am located, clinical research communities are at the forefront of applying VR in psychiatric treatment, with studies on exposure therapy, auditory hallucinations, and automated biofeedback currently taking place. These studies all have a clinical focus and a clinical aim, which is why it feels particularly important to consider the broader implications of how VR is shaping psychiatric treatment. We ought to be thinking about how the technology shapes professional practices, knowledge production, recovery experiences, and therapeutic relations, and not just how it affects treatment outcomes.
One of the studies that I find particularly interesting is called the “Challenge Project”. It is a collaborative research project involving three Regions in Denmark, with Khora, a Scandinavian virtual reality and augmented reality production studio, spearheading the software design. The project constitutes the largest to date VR-based avatar therapy trial in the world, with Pia, whom I introduced in the opening, volunteering to test the experimental form of therapy that the project seeks to develop. The overall aim of the trial is to examine the effect of targeted VR therapy for persistent auditory hallucinations in individuals with psychosis. The purpose of the avatar therapy is to aid people suffering from schizophrenia spectrum disorders – people like Pia – and to support them in gaining control over their auditory hallucinations. Early findings indicate that patients are experiencing increased control over their voices.
The avatar therapy that Pia receives is a form of psychotherapy, and like psychotherapy, as Brandt contends, it is based on a belief in the capacity to know and transform patients according to rational principles (Brandt, 2013). As such, and as Brandt has also argued, the use of VR in psychiatric treatment is premised on a form of ‘cybertherapeutic reason’: a way of thinking about how to use technologies to treat mental illness. Indeed, proponents of VR hope that it will provide immersive experiences that will help transform mentally disordered people into healthy ones (Brandt, 2013). Like teletherapy, VR is a form of mediated care. Unlike teletherapy, however, VR aims to create the illusion of non-mediation. In other words, when immersed into virtual reality during therapy you are not supposed to be aware of the technology, to know that your sense of presence is being mediated. Of course, STS scholars will insist that this illusion is indeed just that: an illusion. All things digital are always already materially placed, but to understand what the illusion means, what it entails, we need conceptual development that more accurately captures the interplay and mutual constitution of the place of treatment and the knowledge produced about the impacts of that treatment.
At the beginning of therapy, patients create a digital representation (an avatar) of the source of their auditory hallucinations (see picture 1). Together with a computer graphics artist, Pia and her therapist collectively collaborate to design the avatars, making visible and manifest what once was not. As such, Pia’s voices are given a face, a gender, and a body. Everything from the proximity of the eyes to the color of the hair can be altered by a stroke of a key. A real time voice modulation feature furthermore allows Pia’s therapist to talk with the tone and particular pitch of the distressing auditory hallucinations, allowing the animated audio-visual avatar to be used in therapeutic role-plays (see Smith et al., 2022). The technology, therefore, affords Pia’s therapist the possibility to “become” Pia’s voices. She now has the ability to shift between speaking as herself, a professional clinician, or as one of Pia’s voices, a manifestation of the unreal. I cannot help but wonder how the therapist chooses what to say and what the implications of her choices are for both Pia and the therapeutic practice. Indeed, what is the epistemic authority of the voice-cum-avatar-cum-clinician? How is it established? And what does it mean for the production of clinical knowledge about the effects of treatment?
Other than deeply changing the therapeutic relations between Pia and the therapist, the use of the VR goggles also changes the socio-spatial circumstances of the therapeutic setup: although the therapist is physically situated in close proximity to Pia, the nature of the therapist’s presence is significantly transformed. Pia can speak to her, possibly sense her, but she can no longer see her. Virtual reality backgrounds physical reality, yet physical reality does not disappear. Indeed, the physical space may still make itself felt: for instance, if Pia suddenly stumbles over the electrical cords or accidentally bumps into the table in front of her. This leaves me thinking about what the relations between these two places are. Are they layered, separate, or entangled? Places may both connect or separate; they may impose order or remain messy. Places undoubtedly arrange people and things; organize relations and patterns of movement; establish certain conditions of possibility, while troubling others. In any case, the place of VR constitutes a highly controlled experimental environment – the “Ultimate Skinner Box,” as some have argued (see Brandt, 2013).
The therapist is afforded complete control over the environment, with the ability to adjust the proximity between the avatar and Pia, to raise or lower the volume of the voice, to change where the interaction takes place (on the beach or in a room) and, of course, to determine what the voice is saying. Despite this control, uncertainties related to disease ontology and treatment effects remain. In VR, they might arguably be intensified.
Uncertainty, knowledge and place
According to Pickersgill (2011), mental health research and practice is continuously confronted with both ontological and epistemological uncertainties due to, among other reasons, the dis-unification of clinical knowledge production. We simply do not know what mental disorders really are. As such, psychiatry arguably exists in a state of “ontological anarchy” because of the wide range of biological, psychological, sociological, and, I might add, digital markers posited to relate to mental illness. For Pickersgill, this leaves clinicians to work as “ontological bricoleurs,” piecing together different knowledges concerning psyche, soma, and society to understand the various disorders of the mind (Pickersgill, 2014). Although the avatar therapy applied in the “Challenge Project” relies on a form of psychotherapy, which is well known, uncertainty about the implications of the experimental treatment in VR are to be expected. While this uncertainty may potentially act as a catalyst for innovation in clinical development, it will also make empirically visible how boundaries between the real and the unreal are drawn in the production of a therapeutic space in practice. Such dynamics will arguably become visible during therapy sessions as clinical professionals are moved to go beyond routine practices, allowing for situations where the role of place in therapy will also be made more visible, as both patients and professionals pay more attention to it.
I suggest that taking reality as a matter of concern (Boellstorff, 2016) might here entail considering how relations between the real and the unreal are negotiated and navigated in practice, and to what end. This means that the question of what is real and what is not real is not one of differences between physical and simulated places. It is rather one of exploring how what is real and what is not is something that becomes enacted in practice. Reality, then, is an achievement, an arrangement of relations. While the categories that make up the real/unreal opposition might need some mutual contamination (see Cooper et. al. 2002), studies have shown that patients like Pia elicit real responses to unreal situations: for instance, when Pia is confronted directly with the avatars of her malevolent voices, she may elicit intense feelings and alter her emotional state. Here, the unreal becomes real as the virtual marks the actual.
Although reality and representation are issues at the very heart of VR, the problem of what is real and what is not real takes on a particular significance in relation to clinical psychiatric contexts, where perceptions of reality may already be taken into question (Marloth et al., 2020). The blurring of boundaries between simulated and physical reality may also come with significant risks for individuals like Pia who already struggle with distinguishing what is real from what is not real. Patients like Pia may experience epistemic uncertainty – is it my voice or that of my therapist that is speaking right now? – or a sense of phenomenological unease due to the manipulation of first-person sensory input. Indeed, VR has the uncanny ability to nudge the human brain to believing things that are fantastical, unreal. This raises important questions about how clinical professionals make judgements about the nature of the real in VR, particularly as the unreal may function as an epistemic resource or ‘epistemological guide’ (Messeri, 2021) in generating new clinical knowledge about the impact and effectiveness of virtual reality treatment. Knorr-Cetina’s (2001) concept of “epistemic object” may be especially helpful here as it directs the analytical attention towards how a broader spectrum of things matter in knowledge production. Knowledge-making practices will also come into focus because epistemic objects are inherently open to interpretation.
Physically responding to a simulated avatar is possible when a sense of presence is achieved. Presence in VR is understood as the experience of being in place, even when one is physically situated in another(Slater, 2018). This introduces the entangled issues of where treatment takes place and what the epistemic significance of that place is. Historically, epistemology and materiality have always been fundamentally entangled in the production of spaces of care, with the careful curation of therapeutic environments thought to play an active role in supporting individual recovery and wellbeing. Place, in other words, has always mattered in psychiatric treatment. From the imposing architecture of Victorian asylums to the ‘comforts’ of the psychoanalytic couch, the spatiality of any therapeutic arrangement has always been contingent on the dominant perceptions about mental illness operant at the time. While STS scholars have long considered the importance of place for the production of knowledge and credible scientific facts, how place makes a difference in simulated environments has yet to be systematically studied (see Bartram, 2020). So what do we make of the place(s) of care that VR enacts and enables? Given that patients are simultaneously present in the physical space of a clinic and the simulated environment of virtual reality, the role and epistemic significance of place in treatment becomes unclear. Being both here and there at the same time unsettles the possibility to easily determine where treatment takes place. For this reason, we might also consider place, like reality, as something that is relationally constituted, an effect of how things and people are arranged in relation to one another in practice.
Clinical VR is inherently intertwined with the rapid developments in technology, an important part of the so-called digital revolution in healthcare. As technology companies become ever more influential, increasingly defining what good spaces of care look like in psychiatric treatment, asking questions about what the implications are for treatment and the development of knowledge about that treatment are vital. Virtual reality treatment in psychiatry is especially interesting, I find, because it fundamentally changes the space of therapeutic interaction. It alters the modes of clinical engagement, reconfigures professional roles, and promises particular therapeutic ends. Where treatment takes place is no longer a given in VR therapy and the boundaries between the physical and the simulated, between the real and the unreal need not only to be navigated, but also to be understood anew. To reiterate some of the questions that occupy me most: what does it mean when a psychiatrist becomes the malevolent voice of a patient? How are therapeutic relations enacted and sustained in a simulated environment? And what is the role of place, when place no longer refers to a physical location like a clinic? Indeed, understanding the epistemic significance of place in virtual reality seems acutely relevant and as something we ought to pursue.
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