Virtual Reality Therapy Island

Jump to the final product video: 🏖️Virtual Reality Therapy Island - VII. Final Proof of Concept in VR

Take a trip with your therapist on this virtual island: Designing to recreate traditional CBT activities in VR

You had a long day at college or you are simply tired from all the presentations in office. You would rather play a game on your XBox than go to the therapy session scheduled now. Infact, even your therapist is tired after back to back sessions in her room. What if I say, that you two can play with each other in the office itself, by going on a virtual retreat of activities, with just a Meta headset?

I. Problem Space

Personal Motivation: Growing up, me and my close ones have witnessed sensitive incidents like suicide of a sibling, loss of a parent, and living with a neurodivergent child, and seen them take regular therapy sessions to cope with the mental and physical stress in their daily lives.

We were not alone, as 70% of adults in the U.S. itself experience at least 1 traumatic event in their lifetime, and all this mental trauma is often converted into physical symptoms. (Singlecare, 2022).

But a recent meta-analysis found that 1 in 5 patients leave treatment before they have reached an acceptable level of recovery, against the recommendation of their therapist. So what is the reason behind this client attrition?

Patient side of the story

Source: Original Persona created on Figma

Therapist side of the story

Source: Original Persona created on Figma

II. Literature Review

I started doing secondary research to understand the problem space better on mental health, therapy methods and client attrition in therapy sessions, and some potential, existing solutions and ideas.

1. Cognitive Behavioural Therapy is called the gold standard in mental health treatment in terms of long-term efficacy (Page, 2012). This is because findings from Rupke (2006) show that people get better when they receive CBT treatment compared with other medical checkups for depression, anxiety disorders, and personality disorders.

Cognitive Behavioural Therapy suggests that our thinking affects the way we feel i.e our thoughts, emotions, bodily sensations and behaviours, all are interconnected to one another. It believes in the idea of neuroplasticity, which states that the patient’s brain can physically change as they challenge negative thoughts via a diverse set of tools and techniques.

A CBT Therapist attempts to come to a shared understanding of the patient’s problem and rather than focusing on ‘think happy thoughts’, he/she promotes a more balanced approach to automatic, irrational thinking (Mind over Mood, 1995).

Source: Resource board created in Figma, Pictures credited in References

2. VR based therapy for dealing with Phobias and Post Traumatic Stress Disorders (PTSD) had significantly lower (16%) dropout rate of patients compared to conventional therapy (57%) i.e 3x less client attrition! Consequently 128 providers in the US itself have been using VR in treatment successfully. (Vincent et. al, 2021)

Some of the major reasons for this difference was that the high customizability in VR — friendliness levels of avatars and the difficulty level of scenes could be changed by therapist as per the comfort level of the patient. Also patients felt that they had a greater sense of control over the fears as they are not pushed into the real world.

Source: Pictures taken from GIS (2023)

III. Artifact Analysis & Creative Inspirations

Traditional CBT Tools

To facilitate therapy sessions, psychologists often use tools and techniques that promote a safe and welcoming environment for self expression for the patient. The latter usually has a hard time opening up and communicating inner turmoils in the first few sessions and the following techniques serve as an ice breaker in in-person sessions between the patient and therapist. [Figure 1] For monitoring their behaviour on a daily basis, CBT based apps are used by patients as well [Figure 2].

Figure 1: Original work made in Figma, Image citations in references

Figure 2: Original work made in Figma, Image citations in references

A video game: Sea of Solitude

After watching the TEDx Talk by artist, Cornelia Geppert, I was immediately intrigued and played an adventure game created by her to help others like her deal with loneliness. She converted her personal demons into 10 different monsters and throughout the narrative

gameplay, the lead character Kay, had to battle each of them.

For example, a fight between a chameleon and an iguana underwater signified how in parental fights, children like Kay are often stuck in between. Or a tiff with similar versions of her in a burning house meant how Kay has negative thoughts putting her down every day.

Source: Screenshots from Original Gameplay from SOS (2023)

Meta’s VR for Good Initiative

Having bought an Oculus Headset for my brother who loves gaming, I stumbled upon how Meta supports the Mental Health pillar and encourages development of apps which can “help people understand how they think, feel and behave in an increasingly challenging world”. (Meta, n.d.) Moreover, playing these apps gave me a first person perspective of the immersive experience and how it could act as a support tool to regular therapy sessions.

Source: Screenshots from Original Gameplay from Meta App Store (2023)

IV. Design Frame

As I converged at the intersection of the 3 concepts of VR, Therapy methods and Health+HCI, I diverged the sub-tasks of the focus area, which were interrelated to each other, in the form of my design frame [Figure 3]. This also helped me move from my knowledge base to my design intent and choose a specific direction rather than being a research wanderer.

Figure 3: Original figure made in Canva

Final design frame one-liner:

Studying how CBT based tools can be used in VR by therapists, to build a safe environment for patients to express themselves, and for therapists to understand them better.

V. Primary Research

Therapists

For this phase, my main goal was to get a first hand perspective of therapists in the mental health arena and obtain answers to specific questions related to my findings from secondary research, and fill in the gaps. I developed an interview protocol to conduct semi-structured interviews online and on-site.

Subsequently I talked to 5 therapists and resident physicians ranging from IU School of Medicine and Dept. of Psychiatry, BetterHelp, AmeliaVR and researchers from India and Australia and I found helpful resources [Figure 4]. I broke down each stage of the CBT treatment and discerned the phases which occur in them. [Figure 5]

Figure 4: Therapy sessions created by one of the therapist who has consented to upload this here.

Figure 5: Original picture taken of pages

Patients

In order to recruit users and use data obtained from patients and therapists during user interviews, for future research beyond the current capstone timeline, I worked on the IRB or Institutional Review Board protocol form. I got approved for it in my 6th revision and got to know how important it is to fill in the users with integral information like safety instruction documents in case of dire scenarios in VR and a user consent form which reassures them that their data privacy is being maintained [Figure 6].

Figure 6: The IRB form (LHS) and the survey link (RHS). Link to survey

Thereafter I conducted semi-structured interviews with 11 users and some of the major takeaways are depicted in Figure 7.

Figure 7: Original table created in Google Docs

V. Design Process

Method: Research exploration and evaluation as an outcome of primary research

I made this treatment map which starts from the initial phase of a patient entering the treatment to the end phase of his/her behavioural change and beliefs [Figure 8].

Figure 8: Original whiteboarding

The treatment map evolved in the form of a journey map, and contained a more in-depth analysis of the list of potential VR activities that would be utilized for intervention at chosen stages of the therapy treatment course. Here, the opportunity area for me as a designer exists at phases 3 and 4 wherein I will act as a mediator between the therapist and patient with VR as a touchpoint [Figure 9].

Figure 9: Original table created in Figma

Framework used: Design Council’s Design Thinking Framework

Figure 10: Framework used from Design Council’s toolbox and edited in Figma

I used this framework [Figure 10] because it was more realistic with its agile structure of going back and forth between the 4 phases between the design frame, the final solution and iterating on the designs after getting feedback from therapists, patients and the teaching team.

Design Philosophy created: Downloading thoughts offline

Source: Original pictures taken of home walls

Converting tacit knowledge in a tangible form by making my thoughts offline on my home walls and in gallery walks in class! Every designer has a different story and I need not rigidly follow already existing design tools. Instead I can take them as reference and work on creating my own philosophy, which I think is simple yet effective for me to tell my story.

VI. From Ideation to Low-Fi sketches and Mid-Fi Prototypes

Along the way of brainstorming and ideating, I learnt some functional and easy-to-use prototyping tools and techniques, that can help visualize and empathize with the users in a better way as a designer. I documented these learnings here.

Source: Original article written on Medium. Link

Understanding the hand gestures in VR by doing bodystorming with the help of paper instructions. Source: Original sketches

User Flow of the therapy island

In order to better incorporate the user feedback received from both therapists and patients, I also created a user flow chart [Figure 11]. Once the patient or the user is made to wear the headset during the therapy session, he/she will find the entrance of an island with a map.

Figure 11: Original sketch drawn on paper

Thereby the user will see the home screen of the therapy island. [Figure 12]. The map will contain 3 activities. The therapist will use his/her computer to select one activity in VR. The user will follow the instructions and complete the activity using the headset. A virtual avatar of the therapist will help the user along the way. Currently, I will be using the Wizard of Oz method and pre-programming the avatar to speak in each activity.

Figure 12: The low-fi version of the home prototype. Original sketch drawn on paper

Sketching Activity 1

The first VR activity [Figure 13 and 14] consists of describing how the patient feels. This will be used as an ice breaker by the therapist, at the beginning of the therapy session and has been inspired by the spinning wheel used in traditional therapy [Figure 15]. As a user, he/she will choose between 3 roads — Happiness, sadness and anger. As the user walks on his/her selected road, for example sadness path, trees are seen. These trees have apples attached to them which further have emotions written on them like delight, joy, excitement, comfort etc. The user will pluck the apples and put them in the basket kept near the trees. The activity ends.

Figure 15: Traditional version of Activity 1. Source: GIS

Figure 13 and 14: Original sketches by Sampada

Sketching Activity 2

The second VR activity [Figure 17] consists of dealing with the patient’s response to a worrisome situation in his/her life, which is used as a regular CBT based session worksheet as well [Figure 16]

Figure 16 and 17: Image taken from TherapistAid worksheet and Original sketch made by Sampada

The activity begins with the user responding to the prompt, of what is making him/her more anxious right now. He/she will respond and a prompt will be given asking how they feel about it a day from now. As the user will walk on the path for 5 steps, he/she will see a sapling grow to become a tree. The prompt will now ask how they feel about the situation, after a month has passed. Finally after taking 10 steps, there will be fruits and flowers on the trees, and the last prompt will ask how they feel about the situation, after a year has passed. The activity ends.

Sketching Activity 3

The third VR activity [Figure 19] transitions the user to a beautiful nature scene. The user will be asked to name 3 things he/she sees, 3 sounds heard and 3 movements observed. The activity ends then. This is used as a cognitive restructuring activity in traditional CBT based sessions [Figure 18].

Figure 18 and 19: Image taken from PsychologyTools.com and Original sketch made by Sampada

Task flow of the therapy island activities

I planned to conduct only the usability testing of these activities which will be used as a VR intervention in between a therapy session. Thus, I wouldn’t be testing the entire experience of a therapy session. However, to further understand every action and step taken to start and end each feature in my VR app, I mapped out the task flow of the Home screen, Activity 1 to 3 and a stress reliever, Activity 4 that I had kept as future scope after the second round of user interviews [Figure 20].

Figure 20: Original sketch drawn on paper

VII. Final Proof of Concept in VR

I have captured major snippets of each of the main three activities and the home screen of the therapy island which I deployed in Oculus Meta 2, using ShapesXR and Unity platforms in the following videos:

This final Proof of concept was created to be used as a 5–10 minute VR intervention in between a CBT based therapy session of 60 minutes, with an actual therapist [Figure 21]

Figure 21: Created in Figma, Illustration taken from GI.

Usability testing was also conducted in gallery walks and semi-structured, one-to-one sessions with potential users.

Figure 22: Original snapshots taken

Update: Final Showcase Day

As a human computer interaction design major, I had pursued this as a year long thesis project. So we had a capstone showcase earlier this week, wherein I presented my therapy island project to professors and students through my interactive booth with props as a luggage to signify that you take the personal experiences that shape you with you on the trip to this therapy island and I dressed as the avatar I created for the virtual therapist.

Image sources: Presentation created in Google Slides

Thank you for reading and watching :) Please let me know if you have any thoughts or feedback, or something you would want to know more in this process!

References

1. McDermut, W., Miller, I. W., & Brown, R. A. (2001). The efficacy of group psychotherapy for depression: A meta‐analysis and review of the empirical research. Clinical Psychology: Science and Practice, 8(1), 98–116. 2. VR therapy. (n.d.). Healthiar. https://healthiar.com/wp-content/uploads/2017/07/comicPsious2.jpg 3. Page, A. C., Hooke, G. R., & Rutherford, E. M. (2001). Measuring mental health outcomes in a private psychiatric clinic: Health of the Nation Outcome Scales and Medical Outcomes Short Form SF-36. Australian & New Zealand Journal of Psychiatry, 35(3), 377–381. 4. Wing, J. K., Beevor, A. S., Curtis, R. H., Park, S. G. B., Hadden, J., & Burns, A. (1998). Health of the Nation Outcome Scales (HoNOS): research and development. The British Journal of Psychiatry, 172(1), 11–18. 5. Jacobson, N. S., & Truax, P. (1992). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research.

For the entire list of references, please click here`