Virtual Psychology

Avatar therapy: From couch to cyberspace

The author is listed as “Samantha Murphy is a counsellor and freelance writer based in Pennsylvania“.

Psychotherapy in a virtual world has its advantages – particularly if the real world is what you can’t cope with.

By my fourth interview, I’d developed a  checklist to use before each meeting. For starters, I would make sure I  had grown some hair. I’d also check that I was fully clothed – I had  learned the hard way about that one. Only then would I teleport to the  interview, hoping that this time my avatar wouldn’t materialise in  anyone’s lap.

Welcome to Second Life, a virtual  world with almost 20 million players globally, where the avatars –  digital stand-ins for the players – create everything around them. Every  cobbled street, every tree swaying in the wind, even the wind itself,  is the product of someone’s imagination.

For some users, though, this isn’t  merely a game. It is precisely this ability to construct and control a  virtual environment that is creating a new branch of psychotherapy –  avatar therapy – in which therapists interact with their clients avatar  to avatar.

On the face of it, this might sound  like a pale imitation of a real-life therapy session. Yet its proponents  say avatar therapy has some unique advantages that take psychotherapy  to the next level. In Second Life, therapy sessions are not confined to  the therapist’s virtual office; they can also involve role-play  scenarios to allow the patient to practise their newly learned coping  skills in virtual environments tailored to their needs. All the while  the therapist gives real-time feedback, like a medically qualified  Jiminy Cricket.

Launched in 2003, Second Life was one  of the first virtual worlds known as massively multiplayer online games.  It was designed not for fighting monsters, but for people to socialise  and, increasingly, emulate real life. Musicians have concerts, artists  display their work and scientists go to meetings. People work, learn and  connect in these virtual worlds. So can they be used for healing too?

As a technophile, I love the idea; as a  psychotherapist used to working the old-fashioned way, I had  reservations. So I decided to meet some of the advocates of virtual  therapy in their own domain, avatar to avatar, to see if they could  address my concerns.

One of my first interviews was with  Dick Dillon, a real-life psychotherapist with Preferred Family  Healthcare, a Missouri-based non-profit organisation that also leads the  field of virtual therapy. In Second Life, Dillon’s avatar is a bald,  square-jawed hunk with a passing resemblance to Bruce Willis. He took me  through a typical therapy session.

Talking by voice chat or instant  messaging, you and your therapist may decide it is time to revisit the  site of a traumatic event – a car crash, say. But in real life it is too  far away, or perhaps you don’t yet feel happy driving. No problem: your  therapist builds, or “rezzes”, the scene in a matter of minutes. Soon  you are driving on a familiar road, with a steep bend similar to the one  that you lost control on in the rain. As you approach the turn, your  anxiety increases and your breaths become faster.

The therapist coaches you, reminding  you of symptom-management techniques. If it all becomes too much, they  zap you instantly back into the office.

According to Dillon, this set-up lets  the therapist give real-time feedback while providing an experience that  feels genuine, yet takes place in the safe environment of a simulation.  The emotions are real. The rewards are real. Only the location is fake.

“When the brain sees a 3D object in real life it  converts it to a 2D object in the visual cortex,” says Jeremy Bailenson,  head of the Virtual Human Interaction Lab at Stanford University in  California. Perhaps that’s why a virtual scene can still provoke a  strong psychological reaction, he says.

Phobia exposure

One of the first applications of  avatar therapy was in treating social anxiety disorder, a crippling  shyness that can confine people to their homes. James Herbert, head of  the anxiety treatment and research programme at Drexel University in  Philadelphia, Pennsylvania, was among the first wave of researchers to  investigate avatar therapy. Encouragingly, clients generally rated the  treatment highly, though there were exceptions. “Some patients and  therapists reported frustration with not being able to see the  individual’s face,” he says, and sometimes technical difficulties  interrupted the sessions.

Avatar therapy has also helped people  with phobias. In real life, the usual treatment is to gradually expose  people to the source of their fear, but this can sometimes be difficult.  An avatar therapist can introduce the phobia source while remaining in  complete control, scaling the experience up or down according to the  client’s reaction.

In fact, many of the conditions  treated by face-to-face talk therapy can also be treated virtually,  including depression and anxiety. Avatar therapy is proving useful for  more diverse conditions too, such as traumatic brain injury,  schizophrenia and Asperger’s syndrome. So far studies have shown similar  success rates to traditional therapy for social anxiety (Cyberpsychology & Behavior, vol 8, p 76) and post-traumatic stress disorder (Cyberpsychology, Behavior, and Social Networking, vol 13, p 3). Dillon’s team will soon publish a study showing its effectiveness in drug and alcohol addiction.

What about the downsides of avatar  therapy – doesn’t it lack the personal touch? “A real therapist dealing  with a real person is more likely to feel ethical responsibility and  care for that patient,” says Christine Webber, a psychotherapist based  in London.

The other major concern is the loss of  body language. For people used to Second Life, this is not as much of a  problem as you might think, according to Dillon. But as a therapist, I  glean a great deal from seeing someone become tearful or shift in their  seat.

It’s a trade-off, say avatar  therapists. What you lose in body language you gain in the eloquent  expression of conscious thought – at least for clients who type in their  responses – as well as the loss of inhibition that comes with  communicating through an avatar.

For people seeking therapy online,  there are practical concerns, too: without visiting a real office with  certificates on the wall, how can they be sure the people offering  treatment are bona fide therapists? 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. Because confidentiality is paramount, one  criterion is that sessions must take place in digitally secure areas.

So are psychotherapists ready to leave  some of their most basic tools behind? “It’s not for everyone,” says  Kelli Turgyan, a social worker practising in Lancaster, Pennsylvania.  “This type of therapy would have to be done by the right type of  therapist for the right type of client.” Because of the lack of  face-to-face contact, only low-risk clients should be taken on, and they  must be willing to use local emergency services if they hit a crisis,  she says.

Despite the downsides, avatar therapy  is gaining converts. There’s no official head count, but each month more  and more therapists seem to pop up in Second Life and other virtual  worlds. A growing number of journal papers and chapters in mental health  textbooks are focusing on avatar therapy too, say DeeAnna Merz Nagel  and Kate Anthony, co-founders of the Online Therapy Institute.

The field is still in its infancy and  the technology is not without its pitfalls, but this new form of therapy  clearly holds promise. However, until the day that I can log in and  find myself with sufficient hair, properly dressed, and less apt to  inadvertently throw myself at complete strangers, it’s clear it still  has a little way to go. But avatar therapy is on the right track. You  could say it’s virtually there.

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