Therapy Meets the Metaverse

I’m standing in the middle of the woods. It’s dark. Very dark. There’s sand under my feet, and a path in the distance, winding between a row of tall, branchless trees. Their trunks stretch higher and higher until they disappear into the night sky, dotted with stars that, eerily, cast no light on the ground below. A glimmer of something beckons from around the twisting path. As I walk, a clearing appears, where a perfectly circular pond lies in front of a massive stone statue of a sitting monk, keeping watch as the water swirls, galaxy-like, at its feet. A few steps further, the tree line breaks, and I’m greeted by three starburst-shaped figures, hovering in midair on a caramel-colored cliff, teetering on the edge of outer space.

We’re definitely not in Kansas anymore.

No, this isn’t a fever dream. I’m taking a test drive of Virgils, one of the latest virtual reality (VR) programs to hit the market. I’m comfortably seated in my living room behind a computer screen. My guides, Virgils cofounders Christian Ulstrup, Beko Jang, and Monet Goldman—digitally represented by those starburst figures—are likewise seated behind theirs, thousands of miles away.

Virtual reality conjures up all sorts of associations. Video games. Headsets. Tron-like universes made up of ones and zeroes arranged in mathematically perfect lines. You can practically hear the lasers and keyboard guitars.

But Virgils is different, Ulstrup tells me. It’s not a game, and its primary goal isn’t to entertain. It exists, he says, because our society is in the middle of a mental health crisis—more specifically, a pediatric mental health crisis—and for some kids and teens, he adds, Virgils could revolutionize our response to it.

Two years ago, Virgils was just an idea. Back then, Ulstrup and Jang found themselves sitting next to each other at a San Francisco venture tech company, where they were developing technology for medical devices. They hit it off, and the self-described later Millennials bonded over having grown up in an era when digital media was just beginning to take shape. As teens, they’d struggled socially and had found solace in video games and the internet—not to their detriment, they say, but as an effective way to find positive connection with others.

“Media doesn’t always have to be used for self-isolation,” Ulstrup explains. “Back then, we learned to use it in interesting and beneficial ways.”

Following that thinking, the two decided to create a VR platform where therapists and clients—specifically, young clients, who feel at home in digital spaces—could work together. They consulted with a design team that crafted fantastical virtual environments and assembled an advisory board made up of tech-savvy therapists, including the Online Therapy Institute’s DeeAnna Nagel, a pioneer in online therapy incorporating digital characters controlled by humans, called avatars.

Several months later, they had a functioning website where therapists and clients could log in to a portal, customize avatars, and walk together through any of 15 different out-of-this-world spaces. One is a forest scene, filled with lush tropical plants and a mist that hangs in the air. Another is a desert at nighttime, with turquoise skies and pyramids filled with winding, torchlit chasms. In another, users search a Mars-like planet for an elusive blue deer hidden somewhere in the virtual world. In any of these environments, users can drop in GIFs and objects like hammers, clocks, gears, and other tools to illustrate moods, or simply to play.

Last September, Ulstrup and Jang brought on Goldman as a cofounder. A fellow Millennial who’d been branding himself “the video game counselor,” he’d been using video games in his private practice, where he’s spent the last three years working with kids between the ages of five and 18. Understandably, he says, the pandemic led to a surge of interest in online therapy. But he also saw a treatment gap, finding online platforms like Zoom limited in their ability to facilitate therapy through play. So when Ulstrup and Jang approached him with their concept, Goldman was sold. “Because of the pandemic,” he says, “many of the kids I work with haven’t had proper social development. My mission has been to help them connect through play again.”

Ulstrup, Jang, and Goldman officially launched the Virgils site last October, after it was deemed HIPAA compliant. Marketing it through word of mouth, they estimate that about 60 therapists are using the platform, all of whom they’ve personally vetted and trained. To gain users, keep barriers to entry low, and stay in line with their mission of public service, they keep—and say they intend to keep—Virgils free to use.

The appeal of Virgils seems straightforward enough; today’s kids already spend so much of their time in online worlds. Rather than go through the time-consuming, sometimes-messy process of trying to build a therapeutic alliance with a child in your real-life office, a space they might find stuffy or anxiety provoking, why not do therapy where they feel more comfortable? In a space where, with buy-in and trust more readily forged, therapy flows a little easier?

But maybe it’s not that simple. What does actual therapy look like in this kind of virtual realm? Other than perhaps being a comfortable space for young clients, does it provide benefits that talk therapy in a real, physical office can’t? The times may be a-changing, but outside of a small segment of the client population, is there really an appetite for this?

The Stickiness Question

The short answer, says therapist Skip Rizzo, is yes.

“Virtual reality isn’t some harebrained, Star Trek, sci-fi scheme,” he says. “Although not too many people think of VR when it comes to healthcare, the scientific literature is extensive.”

Rizzo is the research director at the University of Southern California’s Institute for Creative Technologies for Medical Virtual Reality. He remembers first encountering VR in the 90s, with aircraft-simulator software used to train pilots. Since then, he says, VR has been used in a wide range of settings, including in hospitals to manage pain, and in the Department of Veterans Affairs, where it’s been used by therapists to treat PTSD.

“We know that VR therapy works,” he says. “It works with physical and cognitive rehab; you can role-play with virtual human agents, and you can provide experiential learning that trains clinicians.” More generally, he says, it’s increasingly used by clinicians to treat anxiety disorders, phobias, and trauma—“the granddaddy of VR’s clinical application,” as he calls it.

Rizzo says Virgils represents a newer application of VR, developed over the last 30 years, where users aren’t simply exposed to an environment, but move throughout and interact with it—what’s come to be known as a metaverse. Most often, the therapist and client, represented by their avatars, will meet in the virtual space. Sometimes it resembles a traditional therapeutic space, like an office. Other times it’s a location designed to help clients work through a trauma or phobia. With a client who has a fear of flying, for example, it might be an airplane cabin. Throughout the experience, the therapist can monitor the client’s anxiety, facilitate interventions, and navigate the virtual world with the client at his or her pace. It’s the next best thing to having your therapist on that plane with you.

Although the technology is advancing at breakneck speed, Rizzo says the research on earlier versions of VR therapy shows there’s plenty of promise. He’s been involved in several trials studying it, including one from 2016 coordinated by the Department of Veterans Affairs that looked at the impact of VR on comorbid depression. In the end, when compared with talk therapy alone, VR sessions resulted in more self-disclosure, more revelation of sad events, less worry about depression management, and less shame. In fact, 77 percent of participants said afterward they’d choose VR therapy over talk therapy without VR.

Rizzo offers several possible reasons why. Virtual reality fulfills nearly all of what he calls the seven A’s of breaking down barriers to care: awareness of the intervention, its anticipated benefits, and the degree of acceptance, accessibility, availability, affordability, and adherence to it.

But don’t start packing up your office just yet. This isn’t replacing in-person talk therapy. Rizzo says there’s little evidence supporting the idea that therapists and clients will use VR therapy regularly. In other words, there’s poor adherence. Rizzo says studies show the median number of VR therapy sessions the average user participates in is a paltry one. Just one session.

For now, VR therapy seems to be running into the same problem as so many wellness apps. Sure, they might capture your attention at first, but if they can’t hold it—if they’re not “sticky” enough—then they’re soon forgotten.

“All of this efficacy gets you in the game,” Rizzo says, “but it takes more than that for a VR program to succeed.”

Leaving It All Behind

If Virgils has a stickiness problem, therapist Edvardo Archer hasn’t seen it yet.

Archer, who works with adopted teens and foster children, has been using Virgils with clients since January. And with nearly 10 years of practice under his belt, he says Virgils has been, in his experience, one of the fastest ways to build rapport and connection.

“Play disarms fear,” he says, “and all of us, internally, want to play—especially kids. VR therapy creates the expectation of play. Combine that with a good therapist and an out-of-this world space, and what you’ll see—what I’ve seen—is clients really jump into what matters. It’s blowing my mind.”

But why does it work? And what makes it stick? Archer has several hypotheses.

For one, there’s the use of nonhumanoid avatars. Rather than give you the option of creating an avatar that looks like you—one that’s a particular age, gender, race, or body type—Virgils allows you to select from several floating polyhedrons. Save for a pair of eyes and floating polyhedronic hands, there’s nothing remotely human about it. And that’s a plus, Archer says.

“When you meet with the client, you’re talking to an avatar that isn’t human, that doesn’t follow any sorts of norms or rules,” he explains. “It creates a sense of anonymity. We know from online interactions that this gives you a baseline of confidence to do or say something you normally wouldn’t. You feel safer, more protected.”

There’s another advantage to nonhumanoid avatars, Archer says. If you’re self-conscious about your body, for whatever reason, the avatar allows you to leave that self-consciousness behind. Another benefit: while you can customize the colors and number of points on your avatar, in the end, they all look pretty similar. And when the therapist in front of you isn’t several times your size or age, it levels the playing field. The therapist isn’t so much an authority figure as a partner, a co-adventurer.

“That creates joining,” Archer says, “and joining is the backbone of our profession.”

But what about the content of therapy? Does that change? Archer doesn’t think so.

“I don’t think it’s much different from in-person therapy,” he says. “Your success rate still comes down to factors like the client’s motivation. It depends on me catching the right bus at the right time and asking the right questions. These are still things that have to happen in the office, but the difference is those initial barriers, those hoops I’d normally have to jump through to develop trust. I can say to a client, ‘Hey, help me out with this technology,’ or, ‘Let’s sit over there or explore that over there.’ That partnership begins a lot sooner.”

With so many whimsical scenes to choose from and explore, you might think clients get easily sidetracked and therapists have to work twice as hard to keep them on topic. I ask Archer if that’s a problem.

“Kids are constantly distracted,” he laughs. “But that can happen in your real-life office, too. Most times my clients using VR are ready to talk about whatever we need to talk about. That said, if the client gets distracted and wants to go exploring, I’ll follow that distraction and explore the possible meaning.”

In the virtual world, just like in the real one, all material is grist for the therapeutic mill.

Past Meets Present

In many ways, Virgils straddles two worlds: one that praises the merits of old-fashioned talk therapy and the elemental quality of human relationship, and another one that says there’s a better way and paints a shiny, futuristic lacquer over it.

Even Virgils’s slogan feels a little contradictory: “Return back to reality through virtual reality.”

To be sure, there’s skepticism with technology this new, and rightfully so. Even VR-therapy advocates like Rizzo say there may be unintended consequences. As technology improves, he wonders whether VR therapy might incorporate artificial intelligence (AI) that gives diagnoses and develops treatment plans in the place of a real human being. The allure is strong, he adds. Computers never tire and have encyclopedic knowledge of every therapeutic approach, and everything the client does and says can be stored in a database and easily recalled.

“Will people want to adopt AI therapists?” he wonders. “If they do, we steering them away from proper care, proper diagnoses, and the ability to develop and update treatment as a person changes.”

Ulstrup, Jang, and Monet say they’re aware that VR—any technology, really—can be a touchy subject. Despite ironclad security features, people will always have privacy concerns. And they know that headsets in therapy may conjure up images of a dystopian future, where Mark Zuckerberg sits cackling behind a giant supercomputer filled with your innermost secrets.

But Ulstrup, Jang, Monet, and Rizzo are all in agreement: technology doesn’t fix people; humans fix people. At the end of the day, what makes or breaks therapy isn’t a bright, shiny object, they say, but your bond with your client, the strength of the therapeutic alliance. They agree that VR therapy is—and should remain—just another tool in the therapeutic toolbox.

“We stand on the shoulders of giants,” Ulstrup says. “We think that therapists have superpowers, and we’re here to help them take their work to the next level, to make the impossible possible.”

I have one more question: why the name Virgils? In yet another meeting of past and present, Ulstrup gives me the answer.

“We’re fans of the classics,” he says. “In Dante’s ‘Divine Comedy,’ Virgil was Dante’s guide through hell and purgatory.” Mental health professionals are the Virgils who guide us through difficult situations, toward happiness, health, and growth.”

IMAGE © VIRGILS