Increasing access to psychological treatments for mental illness
Authors: Mark Hayward
Journal: The Lancet Psychiatry (2018)

In The Lancet Psychiatry, Daniel Freeman and colleagues report a psychological treatment for fear of heights.1Freeman D Haselton P Freeman J et al.Automated psychological therapy using immersive virtual reality for treatment of fear of heights: a single-blind, parallel-group, randomised controlled trial.Lancet Psychiatry. 2018; (published online July 11, 2018.)http://dx.doi.org/10.1016/S2215-0366(18)30226-8Summary Full Text Full Text PDF Scopus (168) Google Scholar The treatment entailed a fully automated virtual reality (VR) system, and the study population was an accessible and easy-to-engage sample of participants. The findings were impressive with respect to engagement (90% of participants received the full course of treatment) and outcomes (large between-groups effect size of Cohen's d=2·0 on the primary outcome, maintained at follow-up). These findings are good news for people struggling with a fear of heights (and possibly other similar anxiety disorders), but what do they mean for the psychological treatment of people with more severe and enduring mental health problems, such as psychosis? Psychological treatments for patients with psychosis face many challenges, because access to the treatments can be restricted2Schizophrenia CommissionThe abandoned illness: a report by the Schizophrenia Commission.https://www.rethink.org/media/514093/TSC_main_report_14_nov.pdfDate: November, 2012Date accessed: June 27, 2018Google Scholar and the treatment might generate only small effects.3Jauhar S McKenna PJ Radua J Fung E Salvador R Laws KR Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analyses with examination of potential bias.Br J Psychiatry. 2014; 204: 20-29Crossref PubMed Scopus (325) Google Scholar Symptom-specific treatments targeting either paranoia or auditory hallucinations are generating promising outcomes that might increase effect sizes,4Lincoln TM Peters E A systematic review and discussion of symptom specific cognitive behavioural approaches to delusions and hallucinations.Schizophr Res. 2018; (published online Jan 17.)DOI:10.1016/j.schres.2017.12.014Summary Full Text Full Text PDF Scopus (55) Google Scholar but their delivery in traditional face-to-face formats by expert therapists will do little to increase access (even when technology is utilised, such as in AVATAR therapy).5Craig TKJ Rus-Calafell M Ward T et al.AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomized controlled trial.Lancet Psychiatry. 2018; 5: 31-40Summary Full Text Full Text PDF PubMed Scopus (167) Google Scholar VR is a promising method for delivering psychological treatments to patients with psychosis,6Rus-Calafell M Garety P Sason E Craig TJK Valmaggia L Virtual reality in the assessment and treatment of psychosis: a systematic review of its utility, acceptability and effectiveness.Psychol Med. 2018; 48: 362-391Crossref PubMed Scopus (133) Google Scholar but can a fully automated delivery system increase access? And are greater effects also possible because of the virtual exposure to everyday situations that are experienced as threatening? As we consider these possibilities, at least two caveats can be held in mind. First, the novel aspect of the study by Freeman and colleagues is full automation of the treatment, through introduction of a coach within the virtual world. The virtual coach acts as a therapist and guides the patient through the treatment, thereby negating the need for a therapist to be physically present. Indeed, the authors suggest that such treatments could be used by patients at home in the future (presumably, with no clinical or technical staff present). In a world of rapid technological advancement, this idea might not be too far-fetched. But, is the virtual coach necessary? None of the quotes by patients mention the virtual coach explicitly, which raises a question about the added value of this specific component of the treatment. The pioneers of psychological treatments for severe mental illness need to evaluate the specific contributions made by the novel components of their treatments. This curiosity could be extended to explore the added value of case formulation,7Pain CM Chadwick P Abba N Clients' experience of case formulation in cognitive behaviour therapy for psychosis.Br J Clin Psychol. 2008; 47: 127-138Crossref PubMed Scopus (66) Google Scholar or the visual representation of the auditory hallucination in AVATAR therapy.5Craig TKJ Rus-Calafell M Ward T et al.AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomized controlled trial.Lancet Psychiatry. 2018; 5: 31-40Summary Full Text Full Text PDF PubMed Scopus (167) Google Scholar, 8Hayward M Continuing the conversation about AVATAR therapy.Lancet Psychiatry. 2018; 5: 196Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar Dismantling and other novel trial designs can offer processes through which the active components of treatments can be identified,9Britton WB Davis JH Loucks EB et al.Dismantling mindfulness-based cognitive therapy: creation and validation of 8-week focused attention and open monitoring interventions within a 3-armed randomized controlled trial.Behav Res Ther. 2018; 101: 92-107Crossref PubMed Scopus (49) Google Scholar and can lead to the roll-out of treatments that are no more resource-intensive or complex than is needed to generate some benefits to patients. Second, the demographics of the trial participants suggest that this patient population was very different from people with severe mental illness who we see typically in secondary-care mental health services within the UK's National Health System (NHS)—eg, most of the participants were employed. What additional support might patients with severe mental illness need to engage with a fully automated VR system? Might the immersive experience of VR be more suited to patients with some psychotic experiences (eg, those with paranoia) rather than others (eg, those distressed by hearing voices)? How might the traumatic roots of a patient's psychotic experiences influence engagement with threatening situations in the virtual world that might be linked to the trauma? There seems to be much to learn in these respects. A final consideration relates to the future availability of technological interventions within NHS mental health services that are remote from centres of research excellence. One could be inclined towards scepticism in this respect. However, the i4i Mental Health Challenge Award—a £4 million grant from the National Institute for Health Research—has been awarded to Freeman and his team not only to develop and evaluate VR treatments for patients with psychosis but also (clinical and cost-effectiveness of the intervention permitting) to begin the process of implementation within the NHS. Freeman and colleagues' study represents the latest step in an impressive programme of research that has the potential to transform the provision of psychological treatments to patients with various mental health problems. I declare no competing interests. Automated psychological therapy using immersive virtual reality for treatment of fear of heights: a single-blind, parallel-group, randomised controlled trialPsychological therapy delivered automatically by a VR coach can produce large clinical benefits. Evidence-based VR treatments have the potential to greatly increase treatment provision for mental health disorders. Full-Text PDF Open Access