Advancing science and practice using immersive virtual reality: what behavioral medicine has to offer

By highlighting potential uses of virtual reality alongside challenges facing the field, we hope to inspire researchers to help generate stronger evidence about behavioral medicine-oriented applications using this technology.

ABSTRACT

Interest in immersive virtual reality (VR) technologies is burgeoning as the hardware becomes less costly and more accessible to users, including researchers and practitioners. This commentary outlines the field of immersive VR and highlights applications of its use relevant to translational behavioral medicine. We describe the challenges facing VR applications for health and medicine, and how the core strengths of behavioral medicine can advance theory, research, and practice using VR. By highlighting potential uses of immersive VR alongside the challenges facing the field, we hope to inspire researchers to apply robust theories, methods, and frameworks to generate stronger evidence about the feasibility, acceptability, efficacy, and effectiveness of using this technology in translational behavioral medicine.

Implications.

Practice: Virtual reality technology has great promise for behavioral medicine practice, however, this promise depends upon the engagement of the behavioral medicine community in application development.

Policy: Policymakers should consider the appropriate level of safety and efficacy data required for health and medically facing virtual reality applications before marketing.

Research: Future research aimed at amassing a robust evidence base for health and medical applications using virtual reality is sorely needed.

The social and behavioral sciences have a long tradition of studying mental and behavioral simulation given its central role in self-regulatory processes, planning, problem solving, and coping with stressful circumstances [1]. In the near future, methods used to study and apply mental simulation will be exponentially more powerful because of increasing accessibility and development in virtual reality (VR) technology. VR commonly refers to simulated environments in which people can experience visual stimuli delivered via three-dimensional computer graphics and other sensory experiences [2]. Also central is the immersive capacity of VR, meaning the simulated environment surrounds an individual’s perceptual field such that the user feels psychologically present in the digital world, rather than in their physical reality [3]. Using these technologies will help researchers advance the basic science of how simulated environments can be leveraged to improve health and well-being, and how simulation can advance behavioral medicine intervention and practice.

In this commentary, we provide a brief overview of the current immersive VR technologies that are important to the field; delineate example applications from past research relevant to behavioral medicine; describe the key strengths of behavioral medicine that can be leveraged to advance theory, research, and practice; and address how behavioral medicine can help optimize VR applications in the health and medical arenas.

The main technologies currently relevant to the field are shown in Table 1. However, it is important to note that new versions of these technologies emerge in the market at a rapid pace and the various categories promise to converge in the future. Based on these definitions, we propose that other digital media—such as immersive 360-degree video, augmented reality, and mixed reality—will also be part of the virtual technological revolution relevant to translational behavioral medicine. We refer to VR in this commentary, but conceptually we also include various forms of immersive technology. Historically, VR environments could only be delivered to users via specialized hardware that was heavy and expensive (sometimes exceeding $20,000 for the headset alone), making them inaccessible to most researchers and making most applications inconceivable. Headsets are now far more comfortable and basic versions cost as little as $199, all inclusive. In the near future, it is likely that consumers will have greater access to VR technology, as will researchers who want to reach them.

Table 1.

| Virtual technologies relevant to translational behavioral medicine

Technology	Definition	Common delivery methods
Virtual reality	3-dimensional computer-generated simulations and environments that deliver sensory information. Content is interactive in real-time and is totally digital.	Headsets and sensor-enabled controllers; attached to PCs, smartphones, or standalone, room-based projection systems. Software downloads from specialty providers. Examples: Oculus Rift, HTC Vive
360-Degree videos	Digital, video recordings in which all perceptual views are recorded at the same time. Content is a depiction of real physical space, but not experienced in real-time and not interactive.	Smartphones, headsets. Videos available at general content providers, such as YouTube and Facebook. Examples: Oculus Rift, Google Cardboard
Mixed reality	Integration of virtual and real-world elements to produce amalgamated environments and visualizations in real-time with interactivity.	Headsets, computers, tablets, hand-held devices. Software downloads from specialty providers. Examples: Microsoft Hololens, Magic Leap
Augmented reality	Computer-generated graphics superimposed on the user’s view of the real-world, experienced in real-time.	Headsets, specialized eyeglasses, smartphones, tablets. Software downloads available from general providers, such as Apple App Store, and Google Play Store. Examples: iPhone, Android phone

The consumer growth of VR started with a focus on video games and entertainment but is anticipated to move far beyond the gaming market, with large-scale dissemination of content via the internet and much broader application to areas that historically have been largely unreached. These applications will deliver health-relevant immersive VR content that can be accessed in multiple settings, including home, work, and community environments such as medical settings.

APPLICATIONS OF VR RELEVANT TO TRANSLATIONAL BEHAVIORAL MEDICINE

VR has applications along the translational continuum from basic behavioral science research to clinical applications and medical practice environments, as shown in Figure 1. Within this continuum, there are multiple categories of emerging use areas. On the basic science end (T1), VR has a long history of use as a platform for conducting behavioral and social science research relevant to health and medicine. Use of VR as a research platform has been validated to be applicable to real-world social and decision-making processes [4, 5] and has opened doors to previously impossible experimental approaches. Here, researchers are able to conduct well-controlled experimental research, elucidating causal variables, within ecologically valid environments that comprise any content a researcher can dream up [5]. VR also allows collection of extensive behavioral measures in a continuous and automatic fashion. Examples of VR-enabled basic research include simulated health care communication interactions wherein communication content, emotion, interpersonal behavior, and other variables can be interrogated within the context of a clinical interaction with a virtual human doctor (or patient) [6–8]. Another example is the study of cue reactivity in an addiction context wherein VR can effectively deliver alcohol, nicotine, and other cues to induce craving that can subsequently be studied in the lab [9, 10].

Fig. 1.

| Virtual reality applications across the translational spectrum.

Moving away from the basic science end of the continuum, another primary category of VR application is for training of health care providers. VR-enabled medical training has taken multiple formats—including surgical and procedural training—but most notably for behavioral medicine, VR is being leveraged to train health care professionals and students in interpersonal communication skills [11, 12]. For example, learners can interact with virtual patients who present with varying histories, backgrounds, and medical scenarios, providing tracked and quantified feedback, all within a digital application.

Within the translation to people (T2) and translation to practice (T3) stages (Figure 1) lies direct application of VR for use in health and medical care, such as treating veterans with post-traumatic stress disorder (PTSD) [13] or helping people affected by eating disorders learn new ways to process information about their bodies [14]. Because of the rapid growth and development in this area and the high-stakes nature of patient-facing technologies, here we focus primarily on this category.

VR FOR DIRECT PATIENT CARE AND WELLNESS

A plethora of direct care use cases have arisen alongside VR’s consumer growth, and new applications continue to be rapidly introduced. In the context of behavioral medicine, these uses include mental health, physical activity, addiction, rehabilitation, and pain management, among others. Each area benefits from features of VR in distinct ways. The specific mechanisms through which VR can address these problems include psychological realism, immersion, and embodiment, each of which is exemplified below and examined in more depth via selected cases for the use of VR.

Mental health is a long-running use area of VR application, with research-based foundations dating back to the 1980s. Most frequently, VR has been applied for exposure therapy, in which patients are exposed to objects or situations to address feared stimuli therapeutically. For example, researchers created a psychologically realistic immersive virtual application to simulate combat, which has been used to systematically desensitize patients with PTSD [15], and has demonstrated comparable efficacy [13, 16] to active treatment approaches. Similarly, exposure therapy for specific phobias has been developed over decades and involves exposing patients to immersive, feared stimuli that are psychologically realistic enough to result in reduced anxiety and symptom improvement in real-world phobia-relevant situations [17, 18]. Eating disorders are another related use case that is substantially supported by research [14]. For example, one approach aims to change patients’ distorted thoughts about their body shape and size through exposure to three-dimensional body representations in relevant environments [19].

Pain management is another area where VR applications have benefited from multiple decades of research and development wherein VR environments are supplied to patients for distraction purposes in situations where acute painful procedures are being conducted, and more recently for chronic pain management. These approaches are immersive and block out visual and auditory evidence of the source of pain, occupying one’s mental attention, allowing for a sense of presence—the psychological experience that one is existing in the virtual world as compared with inhabiting the physical environment in which a painful procedure is being performed. Several comprehensive reviews have reported VR pain interventions to be highly successful in a wide array of medical scenarios and with few side effects [20, 21].

As another example, VR environments have been developed to support and encourage physical therapy home activities. These VR environments involve gamification of required therapeutic body movement such that patients perform their exercises precisely and in an entertaining context. Performance is closely measured and monitored, given the ease with which movement data are collected, and such treatment can have high fidelity to therapeutic exercises [22].

In the subclinical realm as well, a plethora of VR environments have been developed to address stress, anxiety, and relaxation. Efficacy data for these applications are rarely available, however, given their recent emergence and the general lack of efficacy assessment performed in this arena. Also, in the community setting, there is a rise of VR-based physical activity applications. Approaches are varied but most capitalize on embodiment—the fact that one’s body movement drives virtual movement in the digital VR world. Consequently, requiring physical movement to play a game is meant to motivate continued activity, and the sophisticated nature of the VR worlds means that activity intensity can be calibrated over time. To date, the evidence is limited as to whether VR gaming approaches to physical activity will be more successful than exergaming approaches of the past [23]. These systems are almost all consumer-facing, and few applications are tested in a scientifically meaningful manner.

In all, VR is already being applied in a multitude of medical and health areas relevant to behavioral medicine, and creative companies and individuals are continually dreaming up new applications for VR in the health and medical space. This will undoubtedly create new approaches that will be efficacious and bring benefit over older approaches. However, this also undoubtedly presents the potential to create approaches that are ineffective and may even have the potential for harm.

CHALLENGES FOR VR APPLICATION IN BEHAVIORAL MEDICINE

Although VR can be applied across the translation continuum for behavioral medicine researchers and practitioners, given the promise of VR for health and health care products, there has been a veritable explosion of applications in this space led by diverse organizations and companies. The participants in the development and implementation of these applications have been similarly diverse. The creation of health and medical VR applications lies at the nexus of game development, 3D art, digital design, tech visionaries, and health/health care practitioners and researchers. In practice, however, the health and health care community is frequently not included in development efforts in a sufficiently substantive way. Indeed, the development process for VR applications often relies on user experience as a primary framework for application assessment during the development phase [2]. For every VR health application development team that insists on amassing a robust evidence base of efficacy and safety for their product before launch, there seem to be several more who instead push applications out in the absence of clinical validation and assessment.

In part, this may depend on the targeted audience. Some VR applications are aimed at health care and therapeutic settings directly, where there is expectation of a clinical evidence base before implementation. For example, many of the current, mainstream commercial applications for psychotherapy and pain management are built on a bedrock of clinical evidence (as described in the previous section). However, an abundance of distribution channels means that VR health applications can be marketed directly to consumers or to environments outside of health care with or without solid evidence as to their efficacy and safety. Given the vast array of domains in which VR applications are being developed, this may present the possibility for harm.

In considering practical issues related to VR application in the behavioral medicine space, we can learn from technology-oriented challenges that have come before. In the domain of electronic and mobile health (eHealth and mHealth) applications, there has been considerable debate about efficacy and regulation [24–26]. Regulation of such applications in the United States is typically weak, and most applications exist outside of regulatory frameworks. Currently, the landscape of regulation for VR applications has so far been similar; however, regulation in this space may evolve quickly, much like the technology itself. At present, in the mHealth and eHealth domains many reviews have noted the lack of involvement among health and health care providers and researchers, and most health-focused applications remain untested. This has resulted in a proliferation of applications that vary widely in quality, wherein even highly rated and professionally recommended apps can spur safety concerns [27].

VR health and health care applications are at an earlier stage in their lifecycle where there is still time to conceive of a greater role for content experts, clinical experts, and evaluation experts in what will become the dominant VR health and medical applications of the future. Additionally, there is reason to believe that some VR apps may pose additional concerns, above and beyond mobile applications, with respect to potential harms given the heightened psychological realism, physical interfaces, and the vast amounts of data they produce. Beyond potential harms, there also is the broad question of efficacy and whether the benefits of VR will be the boon for addressing health and illness that developers expect. Similarly, it remains a question as to whether health and medical application developers will use the benefits of VR to their fullest effect in intervention development, or alternatively whether the siren song of new technology will lead to the development of applications that provide little improvement over established platforms. Consequently, it is time to turn attention to the development of a larger evidence base for health- and health care-based VR applications, where the behavioral medicine community has substantial strength.

ROLE OF TRANSLATIONAL BEHAVIORAL MEDICINE IN VR RESEARCH

There is a strong general evidence base in the field for using VR in some health and medical areas. However, as the technology becomes more accessible there is sometimes a strong push to disseminate applications without proven benefit. Consequently, we envision four important ways translational behavioral medicine can support the growth of evidenced-based VR: communication and behavior change, intervention development frameworks, evaluation and measurement, and dissemination and implementation.

Conceptual and theoretical approaches to communication and behavior change

We envision at least two ways VR can capitalize on social and behavioral science theory commonly used in translational behavioral medicine.

Advancing existing theory to capitalize on VR: VR relies heavily on visual and sensory input as compared with text or static images that are a mainstay of traditional intervention content. The social and behavioral science theories that typically underlie behavioral medicine interventions can be applied to VR, possibly being extended or adapted to suit its unique nature. For example, self-regulation models propose that health behavior is directed by motivational systems supported and revised by mental representations, goals, and strategies. When imagery is used to communicate health information, these processes are thought to strengthen because images provide tangible and material input that provokes stronger emotional and perceptual memories. Existing imagery-oriented theories and those that focus on embodiment could be a fruitful place to start the extension to VR applications because VR’s primary vehicle for communicating information is via imagery and sensory input [28]. Accordingly, we might expect information conveyed in this way to have a stronger self-regulatory effect than other communication modalities.

Similarly, social cognitive principles are already used in VR environments that focus on preventing substance use and relapse for smoking, alcohol use, and drug use [10]. These environments capitalize on providing real-time experiences in refusal skills or managing craving by simulating complex contexts and environmental conditions that might evoke relapse or slips, and may have greater ecological validity because of the immersion and presence afforded in VR [29]. These theories could be applied similarly to future VR applications for health to capitalize on facets—such as rehearsal and variable context presentation—that the technology readily supports. To be relevant, social cognitive theory may need to also encapsulate how simulation, cognitive schemas, rehearsals, and embodiment affect decision making and behavior change. Work on embodiment, for example, can help provide examples of how people may learn or be encouraged to change their behavior via behavioral simulation, motor skills, or sensory information [30, 31].

Using theory as a tool for intervention development: Social and behavioral science theory can be used with intervention development frameworks to help design VR applications. Applying intervention mapping [32] or the behavior change wheel [33] to characterize how elements of a VR environment correspond to different theoretical constructs can inform the communication strategy for the application. Using theory in this way would help systematize aspects of VR intervention development, identification of causal mechanisms, and evaluation. These approaches would explicitly link how theoretical concepts at different levels of analysis—psychological phenomenon, interpersonal interactions, or contextual variables might influence the intended outcomes of a VR application. Applying theory to VR applications that seek to support communication, change behavior, or promote informed decision making could result in more effective VR interventions by engaging people with intervention content in more memorable ways and enhancing motivation for behavior change.

Evaluation and measurement

Perhaps one of the largest contributions behavioral medicine can make to this field is strengthening research design and measurement. Few of the VR applications being developed outside the academic context entail any evidence of effectiveness. However, researchers who have pioneered VR in health to date have clearly demonstrated that the same methodological rigor can be applied to studies using VR as has been used for other communication or intervention approaches [6, 34, 35]. In fact, the control afforded by VR environments matches perfectly to rigorous evaluation designs, experimental manipulation of environmental or psychological conditions, and the collection of both self-reported and behavioral data. However, the field runs the risk of being diluted and marginalized by application developers that do not validate, test, or evaluate the effectiveness of VR environments.

Dissemination and implementation in clinical and community settings

Given the expense and commitment involved with the higher-end VR headsets, at this juncture it is difficult to disseminate VR applications to patients, clinicians, and consumers, except through smartphone-based equipment. However, the quality of the experience is affected by the headsets used by viewers. For example, Google Cardboard can be distributed more easily but may not be as comfortable to use, does not provide as fine-grained visual cues, and is not designed for interactivity, which affects the experience in VR. Many hardware manufacturers, including HTC, and Oculus, are slated to release increasingly inexpensive, consumer-focused standalone headsets that could change potential dissemination strategies.

While the field rapidly changes, behavioral medicine can contribute perspectives from implementation science that would help understand organizational readiness to use VR in home, clinical, or community settings. Certainly, most every company in the VR space imagines a future in which VR is a central personal technology that would make reaching consumers with content beyond entertainment more feasible. At present, however, delivery of VR content outside the confines of controlled research-oriented contexts remains a challenge for the field.

LOOKING FORWARD

The future of VR has been envisioned by “futurists” and “tech evangelists” in Silicon Valley as a technology that will touch all aspects of daily life. Some talk of merged VR and augmented reality systems, coupled with artificial intelligence, as the future of the workplace or the future of family entertainment. While today this still seems like fiction, some writers have even envisioned VR as the future platform of daily life itself. Presently, VR is looking for its niche in broader society, its entry point from a gaming and entertainment technology to a ubiquitous technology. Health, health care, and wellness may be one entry point for VR into mainstream society. Consequently, it may turn out to be of great importance whether the VR applications that dominate in this domain are systematically developed using theory and reproducible methods to generate an evidence-base given the great potential that exists for efficacy and for reach. In addition, to ensure the public’s trust in using this technology as a healthcare intervention attention to security and privacy concerns should also be addressed.

However, most VR start-ups do not share the same models of production that we do in behavioral medicine. Researchers in behavioral medicine are used to the high costs of randomized trials, knowing that after a long period of development and testing, an intervention may not be proven effective. Behavioral medicine also has a tolerance for the long timelines that span submission of a proposal to demonstrating intervention efficacy. VR start-ups that want to generate evidence must grapple with these realities and also with the lack of alignment between academic models like prioritizing publication and transparency, and the competition to bring applications to market quickly [36]. This is a difficult disconnect to bridge. However, models certainly do exist within this space wherein companies partner with academic and clinical researchers to assess and refine VR applications, and also publish trial results as an open demonstration of effectiveness and safety [37–39]. Certainly, companies have also moved to commercialize VR interventions that were developed and have already been proven in the academic and/or clinical space. In addition, health care practitioners have begun to delineate models for evaluating VR approaches through clinical trial methods [40].

Consequently, the behavioral medicine community should consider inserting itself into this arena to offer VR developers robust theories, methods, and frameworks that prioritize proven methods for generating evidence, ensuring confidentiality and privacy, and addressing ethical issues in using VR for health behavior change. Few tech companies are coming to us. Meetings attended by academic and industry VR professionals have almost no overlap, and the longstanding research literature is little known by many in industry. In our experience, however, industry professionals are interested and receptive to learn of relevant research and to discuss the importance of evidence-based intervention development when presented within their space. In addition, the VR industry players have been willing to send representatives to the table to discuss issues of concern when invited. We can begin to make ourselves available by offering our skills and expertise, by reaching out to industry colleagues, and by finding funding and partners to develop our own evidence-based applications. Ultimately, building the potential future face of behavioral medicine in this space is worth doing well.

Compliance with Ethical Standards

Conflict of Interest Susan Persky and Megan Lewis declare that they have no conflicts of interest.

Authors’ Contributions: S.P. and M.L. both conceptualized and contributed to writing this manuscript.

Human Rights, Informed Consent, and Animal Welfare This article does not contain any studies with human participants performed by any of the authors; This study does not involve human participants and informed consent was therefore not required. This article does not contain any studies with animals performed by any of the authors.