Interactional Virtual Reality Therapy as a Response to Necessary Social Distancing

For the purposes of the current discussion VR describes a completely rendered environment, to the degree that “reality” is no longer visible at all. In contrast, AR describes a setup in which the environment is partially rendered, often in the form of an overlay through a technological device, as is the case in “Pokemon Go.” Another good example of augmented reality is the AAMFT simulation training (2019) that has been featured at AAMFT conferences and elsewhere.

An additional distinction worth making is between interactional and individually oriented treatment approaches. Individual treatments like Virtual Reality Exposure Therapy (VRET) are well supported in their applicable literature (Riva, 2005; Krijn et al., 2007), but what appears lacking overall are VR treatments that emphasize the needs of relationships and systems larger than the individual—instances that MFTs are well suited to address. To provide further context, individually oriented therapeutic interventions using VR have been present in psychiatry literature since 1995 (Rothbaum, Hodges, Kooper, & Opdyke, 1995). If the conclusion that VR is unexplored in MFT is true, that is 25 years of progress that has not happened or happened to a lesser degree for the systemic therapy approaches.

There is some investigation that appears to be ongoing into providing VRET over consumer hardware and software, which is to say, typical smart phones (Lindner et al., 2019). Given the ubiquity of cell phones and the current circumstances of isolation during the COVID-19 pandemic, it seems likely that such a research agenda would pay off for the practice of VRET and the clients of therapists who use it. Following are a few examples of classical MFT interventions and ideas about how they might be used in VR. Although there appears to be little in MFT literature that pertains explicitly to the shift of interactional therapy from reality to VR, some creativity with theories and approaches many MFTs will be familiar with paints an appealing picture.

If the conclusion that VR is unexplored in MFT is true, that is 25 years of progress that has not happened or happened to a lesser degree for the systemic therapy approaches.

One thing that seems certain is that the creative approaches to helping families have a lot of potential with the resources of VR hardware and software applied to the therapy.

Milton Erickson is legendary in the field for many properties of the therapy he practiced. “Utilization” in particular is a concept attributed to his mastery of using what he was afforded in clinical situations (Dolan, 1985). Gehart (2013) defined utilization as “finding a way to use and leverage whatever the client presents as a strength, interest, proclivity, or habit to develop meaningful actions and plans that will lead in the direction of solutions” (p. 346). There are some ways that VR technology could add depth or dimension to aspects of the client’s presentation that could be utilized. In a typical VR environment, the appearance of all actors, including the therapist and any clients, are very malleable. This is true for the environment itself, as well. As an example, data gathering for an ongoing project at the Interactional Virtual Reality Therapy (IVRT) lab on the campus of University of Louisiana Monroe featured participants who were in an environment meant to look like a therapy room, but one participant was a bipedal bespectacled banana, and the other defied description somewhat, but may have been picked out of a group using the phrase “yellow humanoid booger, wearing lederhosen.” Although facetious, being able to provide the choice of appearance and environment to clients in this way provides additional non-verbals for the therapist to utilize. Whether these non-verbals compensate for things like seeing the client’s actual face is a matter for further research and praxis. One thing that seems certain is that the creative approaches to helping families have a lot of potential with the resources of VR hardware and software applied to the therapy.

Virginia Satir (1983) popularized the family sculpting technique for many therapists. The purpose of the technique is to “make explicit what is going on. It also brings the present family process picture to life” (p. 251). This is an example of a technique that may benefit from expansion into VR. The increased flexibility and transience of form and space in VR might allow for a wider range of interventions, potentially deepening the intervention.

A typical example of how members of families are positioned to explicate a family dynamic is when one family member is prostrating themselves before another family member, with the second family member looking imperiously down upon the first, often with a finger pointed at him or her. Let’s call them Client A and Client B. In VR, a comparable explication of family dynamics might occur by increasing Client A’s size by 5% every time the phrase “I’m done” is spoken, or some other phrase that is meaningful to the interaction the clients are having. I have memories of several sessions in which one family member would shortly be towering over the others under this circumstance, and I suspect I am not alone. In addition to the initial consequences of the behavior being emphasized in the intervention, the ramifying consequences take on new salience as well. In this example, the client who is experiencing Phrased Explosive Growth may soon be out of earshot of everyone else in the session, inviting a conversation about how rigid, “doubledown” stances in the family impose barriers on communication. This dynamic would not be possible in a videoconferencing session. There is no equivalent proximal element in which the client can move “too far away” from others in the session so that they can no longer hear them. Therefore, it seems that this rendition of the “family sculpting” technique would only be possible in VR technology (for now).

Steve deShazer (1984) wrote “Looking back over all the uses of [the imaginary pill technique], it became clear that the technique was successful when the individual client believed in the magic of pills…We take a pill because the doctor says it will help. An implicit belief in magic” (p. 34). I have focused on presenting some places where VR technology and systemic ideas intersect. This is not to say that there would not be challenges. One of the many challenges would be learning how to do our work safely and help our clients within VR technology. This is where de Shazer’s statement offers a starting point. Clients often follow the therapist’s lead in the therapeutic process, whether the approach being used is well investigated or not. A first step towards making this technology useful for the families we see may be embracing it ourselves.