Developing Virtual Reality Exposure Therapy for treating social anxiety in people who stutter
Lead Research Organisation:
Imperial College London
Department Name: Design Engineering (Dyson School)
Abstract
The research problem and scope of the project: Research objective
The main objective of the current project is to develop a form of Virtual Reality Exposure Therapy (VRET) specifically adapted for the needs of people who stutter (PWS), and to examine whether it is also effective at reducing levels of social anxiety. Another aim of the project is to understand whether this form of therapy can be delivered in a self-led format that can be performed outside the clinic using existing off-the-shelf technology.
Research questions:
1. Can VRET be used for PWS to reduce social anxiety, both subjectively and physiologically? More precisely,
a. Can VRET be effective for PWS with varying levels of social anxiety, both clinical and non-clinical?
b. Can VRET reduce the cognitive-behavioural processes, including anticipation and gaze avoidance, associated with the maintenance of social anxiety?
c. Is baseline social anxiety associated with symptom reduction?
d. Are physical and social presence associated with symptom reduction?
2. Is self-led VRET as effective as therapist-led VRET? In addition, can self-led VRET emulate the level of therapeutic alliance experienced in therapist-led VRET?
3. Does a reduction in social anxiety persist over the course of six months?
Work that has already been carried out: Feasibility reviews of available technology
I have conducted a thorough review of available technical applications and hardware that would allow for conducting this project. As a first step, two main ways of creating virtual environments were compared - computer-generated versus
360 degree video of real environments. The criteria of choice were based on increasing the likelihood of achieving the research aims. Having tested both 360 video and Unity (using C# to program), and comparing the
arguments for and against, I have decided to use 360 video, as this modality offers greater presence with more realistic interaction with characters within VR as well as an easier set up. I also compared a variety of commercially available VR headsets that will be used to conduct the current VRET trial. Based on this review, I decided that the best option for current VRET trials is to use the HTC Vive with integrated aGlass eye-tracking. Whilst the Samsung Gear VR is most similar to the technology that I envisage this therapy using, there is currently no way of measuring eye gaze. The HTC Vive also offers better image quality and a more immersive VR experience at a reasonable price.
Programme of work: Phase 1
Creation of virtual environments
The situations replicated in virtual environments will depend both on information gathered from the literature review and perspectives gathered during focus groups. The final selection of these environments will include a variety of situations to replicate real-life social anxiety as closely as possible. Situations will reflect a variety of challenges including speaking to individuals/groups and receiving positive/negative/ambiguous feedback. Furthermore, situations will be developed in such a way as to elicit the cognitive-behavioural processes of anticipation (e.g., speech planning periods before curtains rising to reveal audience). Virtual environments will be presented using 360 video, filmed using a 360 Ricoh Theta camera. 360 video has a number of advantages to computer-generated environments including increased presence and ease of creation. Creation of these virtual environments will use a double diamond approach. The literature review to date and my research plan has covered both the Discover and Define phases. In the development phase, I will gather views from various groups (e.g., PWS, psychologists, clinicians and speech-language therapists) to support the design process of my environments. From that I will create numerous virtual environments as proofs of concept.
The main objective of the current project is to develop a form of Virtual Reality Exposure Therapy (VRET) specifically adapted for the needs of people who stutter (PWS), and to examine whether it is also effective at reducing levels of social anxiety. Another aim of the project is to understand whether this form of therapy can be delivered in a self-led format that can be performed outside the clinic using existing off-the-shelf technology.
Research questions:
1. Can VRET be used for PWS to reduce social anxiety, both subjectively and physiologically? More precisely,
a. Can VRET be effective for PWS with varying levels of social anxiety, both clinical and non-clinical?
b. Can VRET reduce the cognitive-behavioural processes, including anticipation and gaze avoidance, associated with the maintenance of social anxiety?
c. Is baseline social anxiety associated with symptom reduction?
d. Are physical and social presence associated with symptom reduction?
2. Is self-led VRET as effective as therapist-led VRET? In addition, can self-led VRET emulate the level of therapeutic alliance experienced in therapist-led VRET?
3. Does a reduction in social anxiety persist over the course of six months?
Work that has already been carried out: Feasibility reviews of available technology
I have conducted a thorough review of available technical applications and hardware that would allow for conducting this project. As a first step, two main ways of creating virtual environments were compared - computer-generated versus
360 degree video of real environments. The criteria of choice were based on increasing the likelihood of achieving the research aims. Having tested both 360 video and Unity (using C# to program), and comparing the
arguments for and against, I have decided to use 360 video, as this modality offers greater presence with more realistic interaction with characters within VR as well as an easier set up. I also compared a variety of commercially available VR headsets that will be used to conduct the current VRET trial. Based on this review, I decided that the best option for current VRET trials is to use the HTC Vive with integrated aGlass eye-tracking. Whilst the Samsung Gear VR is most similar to the technology that I envisage this therapy using, there is currently no way of measuring eye gaze. The HTC Vive also offers better image quality and a more immersive VR experience at a reasonable price.
Programme of work: Phase 1
Creation of virtual environments
The situations replicated in virtual environments will depend both on information gathered from the literature review and perspectives gathered during focus groups. The final selection of these environments will include a variety of situations to replicate real-life social anxiety as closely as possible. Situations will reflect a variety of challenges including speaking to individuals/groups and receiving positive/negative/ambiguous feedback. Furthermore, situations will be developed in such a way as to elicit the cognitive-behavioural processes of anticipation (e.g., speech planning periods before curtains rising to reveal audience). Virtual environments will be presented using 360 video, filmed using a 360 Ricoh Theta camera. 360 video has a number of advantages to computer-generated environments including increased presence and ease of creation. Creation of these virtual environments will use a double diamond approach. The literature review to date and my research plan has covered both the Discover and Define phases. In the development phase, I will gather views from various groups (e.g., PWS, psychologists, clinicians and speech-language therapists) to support the design process of my environments. From that I will create numerous virtual environments as proofs of concept.
Organisations
People |
ORCID iD |
| Nejra Van Zalk (Primary Supervisor) | |
| Ian Chard (Student) |
Studentship Projects
| Project Reference | Relationship | Related To | Start | End | Student Name |
|---|---|---|---|---|---|
| EP/R513052/1 | 01/10/2018 | 30/09/2023 | |||
| 2163374 | Studentship | EP/R513052/1 | 12/11/2018 | 11/05/2022 | Ian Chard |
| Description | In a randomised pilot trial, we evaluated the effectiveness of virtual reality exposure therapy (VRET) against a waitlist control condition. Statistical analyses failed to demonstrate the effectiveness of VRET at reducing social anxiety between pre- and post-treatment. We found similar results for fear of negative evaluation, negative thoughts associated with stuttering, and stuttering characteristics. However, VRET was associated with reduced social anxiety between post-treatment and one-month follow-up, through this was not statistically analysed. These findings suggest that our current VRET protocol may not be effective at reducing social anxiety amongst people who stutter, though might be capable of supporting longer-term change. In the same trial, we investigated the role of factors that are theorised to facilitate symptom reduction. These included include outcome expectancy, therapeutic alliance, physical presence (perception of being in the virtual environment) and social presence (perception of interacting with others). Findings showed that physical and social presence were both negatively related to changes in fear of negative evaluation between pre- and post-treatment. However, physical presence, outcome expectancy and therapeutic alliance were positively related to changes in social anxiety symptoms. Furthermore, outcome expectancy and therapeutic alliance were quadratically related to fear of negative evaluation change. Therapeutic alliance was found not to mediate the relationship between outcome expectancy and treatment outcome. These findings suggest that the current VRET protocol affected social anxiety and fear of negative evaluation differently. |
| Exploitation Route | The findings from this trial provide a solid basis for further design improvements and for future research to explore appropriate techniques for widening access to social anxiety treatments in stuttering. |
| Sectors | Digital/Communication/Information Technologies (including Software),Healthcare,Other |
| URL | https://www.frontiersin.org/articles/10.3389/fdgth.2023.1061323/full |
| Title | Virtual reality exposure therapy for reducing social anxiety in stuttering |
| Description | Dataset from randomised pilot trial of Virtual reality exposure therapy targeting social anxiety associated with stuttering. Dataset from study investigating the role of outcome expectancy, therapeutic alliance and presence in treatment outcome. |
| Type Of Material | Database/Collection of data |
| Year Produced | 2022 |
| Provided To Others? | Yes |
| Impact | First studies to investigate the effectiveness of virtual reality exposure therapy for reducing stuttering-related social anxiety, and the factors associated with successful treatment outcome |
| URL | https://osf.io/p3ahn/ |
| Title | Smartphone-assisted Virtual Reality Exposure Therapy for reducing social anxiety in people who stammer |
| Description | This intervention aims to reduce social anxiety experienced by people who stammer using VR exposure therapy. The intervention was adapted in response to Covid-19 so that it could be administered and trialled remotely using a smartphone app and cardboard headset. During the intervention, the users are exposed to a number of virtual environments which replicate anxiety-inducing social situations. They will be asked to perform a number of social tasks which have been designed to be relevant to the experience of social anxiety in stammering. The intervention uses an inhibitory learning approach to exposure therapy, through which the emphasis is on violating previously held expectations relating to a feared stimulus, and inhibiting them with newly developed expectations. A virtual therapist is present to guide users through therapy and assist them with evaluating their expectations. The intervention has received ethical approval and is due to begin pilot trials shortly. This project has been funded through the UKRI studentship. |
| Type | Therapeutic Intervention - Psychological/Behavioural |
| Current Stage Of Development | Refinement. Non-clinical |
| Year Development Stage Completed | 2021 |
| Development Status | Closed |
| Impact | Original design plans for an in-person therapist-guided intervention had to be adapted in response to the Covid-19 pandemic and national lockdowns. Whilst maintaining many of the original elements, the design was overhauled so that it could be administered using smartphone VR in a self-guided fashion. New solutions for mental healthcare are drastically needed, especially in response to the ongoing pandemic. Remote solutions are particularly relevant in this context. While many smartphone mental health apps are publicly available, few have evidence to demonstrate their safety and efficacy. The decision to adopt a remote, self-guided treatment protocol will add vital evidence to the emerging field of remote mental health solutions. the design of the intervention followed a methodical process that focused on integrating insights from people who stutter via participatory design. This provided nuanced guidance in ways literature could not, whilst user testing helped with understanding which features were more or less appropriate for people who stutter. |
| Title | Virtual reality exposure therapy for reducing social anxiety in stuttering |
| Description | Smartphone app used to deliver virtual reality exposure therapy. This app was used in main trial to examine its effectiveness at reducing social anxiety in people who stutter |
| Type Of Technology | Webtool/Application |
| Year Produced | 2021 |
| Impact | App has only been used in experimental trials, and is not available for wider public use. Therefore impacts are limited to findings from trials. |
| URL | https://www.frontiersin.org/articles/10.3389/fdgth.2023.1061323/full |
| Description | Focus group |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Patients, carers and/or patient groups |
| Results and Impact | I ran a focus group with a number of people who stammer to gather insight and opinion to aid the design of VR exposure therapy. This was key to understanding attitudes towards mental health treatment and how new solutions could be integrated into the lives of people who stammer, as well as what features they would like to see in VR exposure therapy. |
| Year(s) Of Engagement Activity | 2019 |
| Description | Mailing list |
| Form Of Engagement Activity | Engagement focused website, blog or social media channel |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Study participants or study members |
| Results and Impact | To maintain engagement with this project and engage with potential participants, I have created a mailing list that alerts subscribers to updates in the project and participation opportunities. I've met with a number of stammering support groups, speech and language therapists and researchers to discuss this engagement and how to promote this mailing list amongst their networks. |
| Year(s) Of Engagement Activity | 2020,2021 |
| URL | https://mailchi.mp/b3d85fb2699b/vrforstammering |
| Description | Podcast |
| Form Of Engagement Activity | A broadcast e.g. TV/radio/film/podcast (other than news/press) |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Patients, carers and/or patient groups |
| Results and Impact | I took part in a podcast episode for a national stammering charity as part of their "meet the researcher' series. I discussed my research with a member of their youth panel, with the intention of engaging people who stammer with this work, and outlining how this research aims to improve mental health treatment for this group. We discussed how treatment for social anxiety could be adapted to the needs of people who stammer, and the importance of new solutions for mental health in stammering, particularly in response to Covid-19. |
| Year(s) Of Engagement Activity | 2021 |
| URL | https://open.spotify.com/episode/73Zut84VJCaREQnBKfzpB5 |
| Description | Presentation at summer show |
| Form Of Engagement Activity | Participation in an open day or visit at my research institution |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Public/other audiences |
| Results and Impact | I participated in the summer show hosted by my department, to engage with the general public and industry about my research. As part of this I presented a poster and held a VR demonstration so that people could experience a social environment in VR and understand how this could be used in the treatment of social anxiety. |
| Year(s) Of Engagement Activity | 2019 |