Depict VR
Depict VR aims to offer young people who hear voices a cost-effective and accessible intervention in a completely novel format to complement current therapies
The use of VR applications in the mental health sector is growing rapidly (Hollis et al., 2017). There is a demand for a digital intervention that is as effective as a traditional therapist-led intervention. Being user-led and far more readily accessible than therapist-led intervention are other benefits of VR-based intervention (Premkumar et al., 2024).Hearing voices is a debilitating phenomenon that disrupts a person’s ability to thrive in society.
Hearing voices is characterised by imaginary voices that are not real and where the person perceives the voices as distinct from the person’s own thoughts (American Psychiatric Association, 2015). Also known as auditory hallucinations in a medical context, these voices can be threatening and malicious towards the voice-hearer and others and command the voice-hearer to respond in a certain way (Parry et al., 2021). Hostility and suspiciousness often arise from the malicious nature of voices (Verma et al., 2021). Voices can also be friendly and beneficial if young people become accustomed to them and can reassure the young person (Parry et al., 2021). It often arises in the wake of a traumatic experience, such as abuse.
Over one million (12%) young people in the UK hear voices Maijer et al., 2017. Distress from hearing voices costs the public purse approximately £2 billion and indirectly costs society a further £4.7 billion in the U.K. (Mangalore & Knapp, 2007) .However, being able to share these experiences with a trusted person is the first step towards managing the voices. Sharing can transform the voice-hearing experience and promote recovery (Place et al., 2011).
Currently, Child and Adolescent Mental Health Services (CAMHS) offer Cognitive Behavioural Therapy (CBT) and antipsychotic medication. Cognitive Behavioural Therapy is costly and has limited efficacy for adolescents (Pyle et al., 2019), and there is no specific evidence base that CBT works for young voice hearers. Antipsychotic medication is contested because of the adverse side-effects (Pyle et al., 2019). Parents hesitate to reach out to the CAMHS out of fear of not receiving help, fear of the services aggravating their child’s stress and anxiety or fearing that the engagement with services would disrupt the child’s school activities (Parry & Varese, 2021). Currently, CAMHS cannot meet young people’s preference for face-to-face contact with a therapist (Stafford et al., 2015).
Depict VR is a virtual reality intervention aimed at the under-served young voice hearer population, both those at risk and those with a clinical diagnosis, with the intention of offering a faster route to effective treatment and encouraging young people to seek help.
Family and narrative therapies have been identified as a very promising route to helping young voice hearers. Depict VR leverages many of the powerful features of VR, namely immersion, interactivity and shareability. Tasks in the virtual environment encourage young people to disclose their challenging experiences and have a constructive dialogue with their confidante.
Sharing their experiences creatively with a trusted confidante in a virtual space can improve the young person's social interaction and aid wider social functioning.
Depict VR is intended to be delivered through established CAMHS units and made available as an easy-to-access, cost-effective tool to provide effective early intervention for young voice hearers.
It is vital to involve a trusted confidante when engaging young voice-hearers in clinical intervention (Mayer et al., 2022). Family therapy encourages people who hear voices and their carer to communicate constructively, and it is especially effective with young people (Rinne et al., 2021). The carer plays an important role in helping young voice-hearers to understand their experiences and access clinical support (Maijer, Kim et al., 2017). Besides, the carer may require more support themselves to facilitate that support (Parry & Varese, 2021). Alternatively, a trusted confidante could be a close friend if young people struggle to engage with their close relative. Depict VR harnesses VR-based technological advances in a self-guided format to build relationships and minimise the costs (time, effort and expertise) of a clinical practitioner. A self-guided VR therapy for social anxiety gives the user control over their social fears by allowing them to increase the exposure to different threats by themselves (Premkumar et al., 2024).
Our initial engagement with voice-hearers as part of patient-and-public involvement (PPI) has revealed that carers could benefit significantly from engaging with the young person’s experiences of hearing voices. Carers could gain meaningful understanding of what the young person is going through and develop deeper compassion. Our PPI participants also felt that sharing their experiences via a VR application could be more acceptable than current face-to-face methodologies. Thus, a VR application would be a fun and engaging interface for young people to involve family/carer in understanding their voices.
Family Intervention with CBT is recommended as an alternative to medication (National Institute of Health and Care Excellence, 2013) and this element of sharing experiences with a carer is central to Depict VR.
New modes of treatment must be more holistic, rather than a one-size-fits-all approach (Mueser et al., 2017), and Depict VR aims to achieve this through its multi-sensory and interactive elements.
Work is underway to understand the best routes to treatment, including Coping Strategy Enhancement which aims to train patients in developing specific coping strategies according to the specific symptoms they display (Hayward et al., 2017). VR technology can further realise this holistic approach by creating deeply immersive experiences that minimise the risk of overexposure to actual feared situations. Another feature of Depict VR is a narrative-therapy format. This approach is already showing promising results in VR based therapies for severe mental health problems such as post-traumatic stress disorders. Depict VR builds on the strengths of these existing interventions and the lessons gleaned from the design of a self-guided VR therapy for social anxiety, another VR-based application (Premkumar et al., 2020). The self-guided VR therapy for social anxiety gives the user control over their social fears by allowing them to increase the exposure to different threats by themselves (Premkumar et al., 2020).
As the scope of Depict VR grows, we plan to develop the concept further by including other functionality that could help the users explore their experiences further and build new positive narratives about their voice-hearing that improves their psychological, physical and social quality of life (Place et al., 2011). Narrative therapy uses the patient’s personal life story to unravel a mental health problem and re-frame the problem positively and constructively (Georgieva & Georgieva, 2020). By adding additional storytelling functions to the application in the future we aim to amplify the benefits of both narrative therapy and family therapy (Becvar & Becvar, 2007). Depict VR can help the young voice-hearer and their carer develop new, positive narratives about voice-hearing, exploring the role of humour in this process, and find solutions to this problem (Place et al., 2011).
Whilst a focus of Depict VR is to help young voice-hearers, we believe the application can also help older voice-hearers and can be effective in treating similar mental health conditions that are currently treated with narrative and family therapy, such as post-traumatic stress disorder and eating disorders (Georgieva & Georgieva, 2020).
The primary goal of Depict VR is to foster constructive dialogue between the young voice-hearer and their trusted carer. Research shows that such a dialogue has great potential to bring about positive outcomes for both the voice-hearer and their carer (Parry & Varese, 2021). A key step in this process is to find a comfort zone where the young voice-hearer can share their experience with their carer who in turn can glean meaningful insights into what the young person is going through and develop a shared strategy to reduce the distress of the voices. By closely monitoring the use of Depict VR, we aim to develop the application such that users could access the treatment without the need for a specialised therapist.
A secondary goal is to embed equality, diversity and inclusion (EDI) in the research process. We observe EDI in recruiting researchers, the PPI representatives and participants who possess or have understanding of the lived experiences of marginalisation through protected characteristics, such as race, religion, disability and sexuality, to develop and test Depict VR. Embedding lived experiences of EDI of the research team and research participants in the research enhances ingenuity in the design of the VR application and broadens the scope of Depict VR to a diverse population.