Overcoming Self-Critical Attitudes in Virtual Reality

High levels of self-criticism and shame are damaging to mental health and are thought to prevent patients from recovering. Despite this most psychological treatments have a more general focus and do not specifically target self-criticism and shame. Developing more targeted therapies is likely to bring about greater symptomatic improvement in a shorter time. One recent development is compassion-focussed therapy, which reduces self-criticism by enabling patients to feel greater compassion towards and acceptance of themselves. This is generally delivered by a psychotherapist in the course of one-to-one treatment. Major use is made of imagination-based exercises, building on research showing that images tend to have stronger emotional effects than words alone. However, not all patients have sufficient visual imagination and, more importantly, what they are 'seeing' remains unknown to the clinician. Although the results of this approach are encouraging, finding more efficient and scientifically testable ways of delivering psychotherapy is currently a priority.

Virtual reality is a term used to refer to computer-generated environments that have many of the properties of real environments. For example, they may enable participants to navigate in different directions, interact with computer-generated people ('avatars'), or make choices of the kind they would in a real environment. Research has shown that participants often respond to aspects of these virtual environments as if the environments were real, even though they know they are not {Sanchez-Vives, 2005 #40}. Moreover, recent work has shown that people may experience the illusion of ownership of a life-sized entirely virtual body that they see from a first-person perspective through a virtual reality headset as substituting their own real body. They then experience emotional reactions when events occur in relation to their virtual body {Normand, 2011 #38;Slater, 2010 #23}. This can become a powerful transformative tool.

These developments provide new opportunities to induce emotions such as self-compassion in self-critical individuals and thereby help reduce their symptoms. The project will involve developing a set of immersive virtual environment applications where through interaction with virtual human characters patients can experience both the receiving and giving of compassion to others. Moreover, the body transformation capability of modern virtual reality systems can be used to give patients appropriate feedback in the form of changes to their self-representation that match their increasing capability to be self-compassionate rather than only self-critical. A key aspect of the project, and one in which patients with psychiatric problems will participate, is to determine scenarios, expressions, and gestures that convey compassion as strongly as possible.

The project will involve two initial studies in which the methods are developed using healthy volunteers who are selected for being high in self-criticism. We will expose them to several sessions of self-compassion-induction in virtual reality, assess its effectiveness, and measure how long changes last. Finally we will use the knowledge gained to use the virtual reality scenarios with psychiatric patients reporting high levels of self-criticism. We will also measure the extent and duration of reductions both in self-criticism, associated emotions such as shame, and other symptoms.

An effective technique for reducing self-criticism and shame which reduces the need for expensive therapeutic time will have numerous benefits. For example, it may make treatment easier for people who are unwilling to attend mental health facilities. It may also be a flexible, rapid, and readily available intervention for individuals who are feeling suicidal. Children and adolescents at risk of developing later disorder because of high levels of self-criticism may also take readily to this form of prevention.

Compassion-focussed therapy is aimed at reducing self-criticism and shame. Within virtual environments techniques of multi-sensory integration can be used to generate the illusion that the virtual body of the participant is their own body: (1) adopting first person perspective; (2) visuo-motor integration; (3) visuo-tactile integration; and (4) viewing 'themselves' through a virtual mirror. These components give a powerful illusion of ownership and generate strong reactions in response to events that occur to the virtual body. These developments provide opportunities to induce self-compassion in self-critical individuals and reduce their symptoms. The project will involve two initial studies in which the methods are developed using healthy volunteers. A within-subjects study will test if self-critical volunteers experience more self-compassion in response to a virtual environment involving self-compassion than to a compassion-based writing task or a neutral control condition. In the virtual reality scenario the participant will experience embodiment in a virtual body that resembles very much their own. Embodiment will be induced through the factors mentioned above and the participant will interact another virtual character who will engage in compassionate interaction with the subject. The other virtual character will also resemble the patient - thus providing a direct metaphor for the patient of being self-compassionate. Over time the body self-representation of the patient can transform its appearance to look more and more confident and non-self critical. A second longitudinal study using similar participants will test the gains to be achieved with three repeated sessions. Changes in self-compassion and physiological arousal will be assessed at baseline, after the intervention, and at three-month follow-up. The virtual reality scenario will then be tested with psychiatric patients reporting high levels of self-criticism using the same design as Study 2.

The first group of non-academic beneficiaries are patients with diagnosed disorders in which
self-criticism plays a major role and is thought to be a maintaining factor. These include major
depression, particularly chronic and recurrent depression, eating and body image disorders,
posttraumatic stress disorder, dissociative disorders involving internal critical voices, and
certain personality disorders including borderline, avoidant, and dependent subtypes. Virtual reality based interventions that can increase the capacity for self-compassion may play a number of important roles. First, they may strengthen commitment to treatment in patients who are ambivalent about initiating it (common reasons are because they fear criticism or feel they do not 'deserve' to take up NHS resources). This could help to reduce missed appointments and improve service efficiency. Second, they may reduce symptoms in the short-term. It is not known at present whether they would be effective as a stand-alone
treatment or would be better considered as an adjunct treatment integrated with a comprehensive management plan. They can be used flexibly as part of a home-based treatment plan, thereby addressing the often neglected needs of patients who find it hard to attend hospital or clinic appointments. Thirdly and most importantly, the interventions should strengthen resilience in the face of future challenges and disappointments. In addition to their use as therapeutic tools in structured treatments delivered by health professionals, the accessibility of VR interventions also makes them potentially suitable for self-treatment (for example, via websites hosted by the NHS, charities, or other providers where appropriate guidance and monitoring can be made available). The interventions may also have particular benefits in the management of impulsive suicidality where the availability of an immediate and flexible resource, particularly one that can be readily accessed from home, can be critical. The second group of potential beneficiaries are individuals with high levels of self-criticism who are at risk of developing disorders but have not yet done so (for example, children of parents with serious psychiatric disorders or substance abuse). Previous research has identified evidence for many routes to the intergenerational transmission of a propensity to disorder. Apart from genetic vulnerability, the irritability, poor impulse control, and lack of
parenting resources that often accompany psychiatric disorders have been found to be associated with increased negative self-attitudes including self-criticism in their children. It has been shown that group interventions with the children of depressed parents can successfully reduce later morbidity (Clarke et al., 2001). Virtual reality based interventions may be particularly acceptable to children and teenagers in addition to costing less than comparable face-to-face methods such as the cognitive restructuring groups.
The third group of beneficiaries will be clinicians who will receive education about the therapeutic opportunities offered by virtual reality. At present clinical applications of this technology are largely limited to treatments for phobia and for combat-related posttraumatic stress disorder (Gerardi, Cukor, Difede, Rizzo, & Rothbaum, 2010). In these applications fear-inducing or traumatic environments, such as war zones, are simulated in order to assist in the process of desensitization of fear. Most clinical conditions, however, involve an excess of other emotions such as sadness and anger, and a paucity of positive emotions such as compassion. The opportunities to manipulate and study these other emotions will be disseminated to clinicians through conference presentations and workshops, as well as a dedicated website. The timescales involved will become apparent with the measurement of immediate and longer-term impact of exposure to the self-compassion scenarios (see Pathways to Impact).