The Costs and Benefits of Virtual Reality in Psychotherapy By Tom Medlar, LMHC on 8/22/23 - 12:21 PM

Learning to Weather a Patient’s Emotional Storms

Edith typically experienced a fire-hose intensity in the flow of her emotions. She would dye her hair in bright colors, and these colors changed almost as often as her moods. She could be washed over by waves of anger or sadness. She frequently stormed in rage at her caregivers in the nursing home, or on the phone with her son. During psychotherapy conversations, her anger often dissolved into tears. The symptomatic features of her Bipolar I disorder were like a flashing neon sign on her forehead.

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Part of the therapeutic work with Edith’s case was to educate the staff that her dramatic and unpredictable swings of mood from manic to depressed and her sometimes rapid speaking were elements of her illness. Edith would also verbalize sharply critical comments to her caregivers: “You don’t even care, you don’t listen, what do you get paid for, anyway!” I thought it was important to help the staff to appreciate how reacting with strong personal emotions to her symptomatic behaviors might provoke even greater instability. They were taught to maintain a sense of role boundaries, avoid personalizing her actions or comments, establish clear expectations for daily care, set limits on unreasonable or unacceptable behaviors, and see how those steps would add to the effectiveness of their care and to their professional satisfaction.

The Pain of Virtual Rejection

One morning upon greeting Edith, I was assailed with, “My fiancé dumped me!” As I sat down, I thought, “what fiancé?” She’d not been in a relationship. Edith had a tablet computer and spent many hours playing a virtual reality game. Her avatar was a slim and pretty lady who owned a florist shop and was a personal fitness trainer. As she was interacting that morning with the male fiancé avatar, another female avatar approached and claimed that he was her boyfriend, and the male character “virtually” walked away with the other female character.

In response to our conversation, Edith was able to acknowledge that she had designed her avatar as an entertainment, and a partial fulfillment of things desired yet not available in her present life. But she was unable, at that moment, to realistically distinguish between herself and her fantasy avatar, or to distinguish her emotions from those she projected onto the avatar. The stress of the situation triggered a psychotic episode for Edith. She experienced a loss of ego-boundaries.

I consulted with team members at the facility about ways to manage Edith’s care and treatment. Psychiatric hospital care was not indicated because she made no threats to herself or to others, and an involuntary admission might add to her sense of rejection from persons and supports available to her at the home. Safety checks every 15 minutes were unobtrusively put in place, and staff would make frequent, brief contacts to help her regain her sense of self and her composure. Privately, I wondered if one day I might need to develop a therapy avatar and enter virtual reality settings to conduct therapy interventions.

Four years later, I worked again with Edith at a different nursing home. She had been living in an apartment and was helped by home-based care providers. She’d become ill with an infection, went to the hospital, then to the nursing home for further care prior to discharge home. Since I last worked with her, Edith had experienced significant diminishments in her eyesight, her memory, her mobility, and her overall functioning. She did not remember having worked with me in the past. As we sat for therapy one morning, Edith said that she’d been trying to compose and memorize a poem, because she could not write due to visual loss.

She dictated the poem, and I wrote it down so she could bring it home with her. In her poem, Edith was confronting the many losses she’d experienced, and additional ones she anticipated. Her poetic reflections were sorrowful yet realistic and reasonable given her situation. She showed no indications of psychotic symptoms and was no longer using a virtual reality game. “I know it’s getting darker for me,” she said, “But I just have to face it.” Her medical condition had worsened over time, yet she showed an improved psychological ability to deal with her circumstances. Edith was also more comfortably willing to rely on people in her life who provided helpful services.


Postscript: Virtual reality systems are playing an increasingly prominent role in entertainment, education, business, and in the treatment of mental illnesses. Will the use of virtual reality be a positive influence in all cases, or might it be risky or possibly harmful for some? Might virtual reality headsets be a sort of psychosis-induction device for some vulnerable people? How will we as psychotherapists better understand how risks and benefits of virtual reality might vary for different people? Time, experience, and research findings will help guide our future steps. But we can at least proceed with a sense of caution, as well as curiosity about potential new and helpful approaches.

Questions for Thought and Discussion

How might you have clinically addressed the situation with Edith and her virtual fiancé?

What are your thoughts about the use of AI in psychotherapy?

Would you like to gain familiarity with AI in therapy? If so, what kind and for what purpose(s)?

File under: A Day in the Life of a Therapist, Musings and Reflections, Therapy & Technology