Forget the couch

We make people do fairly disgusting things,” says James Herbert. “Not anything dangerous or harmful, but we make them eat potato chips and with their hands all greasy and salty we make them rub their hands in their hair, and on the floor — then eat something else. That’s very disgusting to these people and it gets their anxiety very high.”

Herbert is a therapist. A a professor of psychology and director of the anxiety treatment and research programme at Drexel University in Philadelphia, he works with people who have phobias. The routine he has described helps patients with an obsessive-compulsive fear of contamination.

“With anxiety disorders,” he explains, “the common denominator is exposure. My wife is scared of mice. If I were to treat her, I would expose her first to images of mice from magazines and from Google. Then a toy mouse. Then she would hold the toy mouse, then a real mouse in a cage, and then take it out of the cage. Eventually, you lose your phobia.”

Exposing patients to the thing they fear is not in itself remarkable. What’s different about Herbert is that he delivers his therapy on the virtual reality platform Second Life – and he’s not the only person doing it. Indeed, The Psychologist magazine describes “virtual therapy” as the most exciting opportunity facing the profession for a generation.

Therapy is now just a click away: one American online therapy site, Breakthrough.com, says it has signed up 900 psychiatrists, psychologists counsellors and coaches in just two years. Another sign it’s hitting the mainstream came in the summer when Web Therapy, a comedy starring the Friends actress Lisa Kudrow that pokes fun at three-minute webcam therapy sessions, moved from the web to American TV.

There are many reasons to welcome virtual therapy. It enables therapists to do things that would otherwise be impossible. For instance, somebody scared of flying could practise taking off several times in a single hour-long session, without the cost and inconvenience of real flights.

In Second Life, people can meet in a setting that resembles an ordinary therapy situation — Herbert’s is a room with pale floorboards, two comfortable chairs facing each other, a large interactive whiteboard, and a view of the sea — or, if they prefer, in a treehouse, round a campfire, or in a remote lighthouse.

The most useful setting may resemble the kind of place where clients experience problems: inside a plane, for flight-phobics, or somewhere filthy, for germ-obsessives, or in a kitchen where family arguments might flare out of control.

Perhaps most importantly, patients who, in the real world, live far from a therapist can have treatment without even leaving home, while for therapists the virtual world offers access to more clients than might otherwise be possible.

In Sweden and Canada, this kind of therapy is conducted by video conference, using high bandwidth. But that’s very expensive, so Herbert uses Skype or Second Life, both platforms that anyone can use on a PC at home.

In a study involving social anxiety disorder, Herbert and his colleague found that Second Life helped them to reach extremely shy individuals who might not have dared to venture out for treatment in the real world. “We were concerned that using avatars they might feel too removed from the therapy and it wouldn’t work,” Herbert says. “But we were surprised and pleased that people did identify with their avatars.”

With social anxiety, if a man is afraid of rejection Herbert asks him to interract with a woman and maybe ask her for a coffee — only to be rejected, even quite brutally. “They have an idea that they can’t handle the situation, and we show them that’s not true. They can do it.” In the past, to enact this kind of rejection, Herbert would have had to bring in an attractive student to interract with the patient. Not any more. “If the guy likes blondes, we make the avatar blonde. It doesn’t matter, as long as it has a female voice.”

Additionally, Herbert encourages patients to leave the therapy room and enter the wider world of Second Life; perhaps go into a bar and strike up a conversation. “Afterwards, we assign homework to practise in the real world — strike up two conversations a day with people you wouldn’t normally talk to, for example.”

But not everything about virtual treatment is convenient. Therapists and patients alike complain that they can’t see each other’s faces. From the therapist’s point of view, this can have a significant downside — they can’t smell the alcohol on somebody’s breath, or read the body language. And it’s well established that people can “put on” a persona in the virtual world that they don’t have elsewhere.

Simon Bignell at the University of Derby has been investigating online communication among people with autism and Asperger’s, and found there’s little difference between them and “neurotypical” people. “You’d expect to replicate the deficiencies in their social communication skills from the real world,” says Bignell. “But the virtual world is levelling the playing field. A lot of people use text there rather than speech. You have to be succinct, to the point and unambiguous, which suits people with a condition such as autism.”

Alessandra Gorini at the Applied Technology for Neuropsychology Lab in Milan says virtual therapy works best if the therapist and patient have previously met each other.

One reason this might suit patients is that online therapy is almost entirely unregulated. While researching this story I found an American who claimed, in a comment posted on a website, to have conducted online therapy for some years, always carefully observing professional guidelines. But when I got in touch he denied that. He turned out to be a IT guy and virtual world enthusiast who once worked with a client interested in setting up virtual therapy but who had pulled out precisely because of concerns over guidelines. In other words, the claim he posted in that comment was false. What to believe?

The Online Therapy Institute, a mental health training body in Second Life, is pushing for professional standards to be agreed across this emerging field. It offers a “Verified by” logo that therapists who meet its standards can display on their websites. Kate Anthony, a psychotherapist and co-founder of the Online Therapy Institute, believes that once such credentials are in place the lack of face-to-face contact is a plus. “The lack of a physical presence cuts through all the ‘white noise’ — the biases that a physical presence creates.”

Therapists claim they can tell a lot about the people they are treating from, say, the appearance of their avatar — indeed, they may be able to help merely by encouraging changes to the avatar, because research shows that giving short people avatars that are tall will make them more aggressive in negotiations.

Second Life isn’t the only option: there are other simulation platforms. One American substance-abuse programme has been given nearly $900,000 to spend on a virtual facility in OpenSim. Preferred Family Healthcare claims that only 10 per cent of clients fail to complete their treatment programme in the virtual world, while as many as 65 per cent drop out in the real world. Additionally, the virtual programme provides far more hours of help each week. Users are encouraged to get to know the virtual world by learning to use it with their counsellor, which additionally supplies that valuable face-to-face contact.

Therapists also felt that OpenSim provided a higher level of privacy than Second Life, and the efficacy of the programme was demonstrated when participants went on to establish a virtual meeting of Alcoholics Anonymous.

Heather Foley used yet another simulation platform customised for therapists to work with people like Joe, a teenager having trouble getting on with his mother. Foley role-played his mother, while Joe played himself.

At first, Joe refused to engage, moving his avatar to make it flee from Foley’s through the computer-generated town’s streets and along its beach. Foley, however, followed with her avatar. “I made the virtual mum avatar chase Joe’s avatar everywhere so Joe would realise he couldn’t find a way out of a conversation.”

Foley reports that Joe had a breakthrough at the end of the seventh session, when she used the programme’s “after action review” feature, to replay sessions from any avatar’s point of view. Seeing the interaction from Foley’s — or his adoptive mother’s — perspective, Joe recognised that his behaviour in the virtual world, and by extension in the real world, too, was “inappropriate and hurtful”. The exercise gave him new insight. “I looked ridiculous because of how I acted,” he now admits.

So there’s a lot going for virtual therapy. As in any patient situation, you have to negotiate terms — some practitioners will operate online pro bono; others will expect a fee.

But there are disadvantages: if you don’t have a state-of-the-art computer, you can forget it. A lot of people find that their IT set-up is inadequate, which perhaps explains why only a small percentage of Second Life registrations lead to users actually engaging with the platform. Also, even among people who are able to use it, virtual encounters can have glitches. Voices may not be transmitted clearly, for instance. And it appears that younger patients adapt more easily to having an avatar than older ones.

Herbert acknowledges these shortcomings, and says that’s why he uses several different platforms. Sometimes he encourages patients to take a laptop to coffee shops and to communicate with therapists using Skype before attempting to make contact with a real person near by. If Skype fails, he says: “We sometimes have them call us on the cellphone. You have to use a variety of methods — and be creative.”