Virtual Reality in Treatment of Non-suicidal Self-Injury
Info: 7825 words (31 pages) Dissertation
Published: 25th Feb 2022
Virtual reality (VR) has received attention in recent years due to its ability to transform environments and captivate users. Though most VR marketing has been targeted to the entertainment and video-game industries, it has also been identified as a useful tool in the treatment of a number of psychological disorders. Defined as an immersive or embodied technology wherein an individual experiences presence similarly to actual (or un-mediated) reality, VR has several unique affordances that make it useful in mental health contexts.
First, virtual reality can be employed to elicit emotions in built environments that simulate real-life scenarios. This is attractive for psychological disorders that involve re-experiencing, or anxiety specific to certain environmental triggers like phobias, post-traumatic stress disorder and social anxiety disorder (Opris, Pintea, Garcia-Palacios, Botella, Szmoskozi & David, 2012; Powers & Emmelkamp, 2008; Botella, Serrano, Banos, & Garcia-Palacios, 2015).
Second, as an embodied technology, VR can be used to facilitate or encourage individuals to tune in and experience one’s body differently. This affordance has already been used in the assessment and treatment of eating and body disturbance disorders (Gutierrez-Maldonado, Wiederhold, & Riva, 2016; Riva, Bacchetta, Baruffi, & Molinari, 2001) and phantom limb disorder (Rogers, Lau, Huynh, Albertson, Beem, & Qian, 2016; Murray, Pettifer, Howard, Patchick, Caillette, Kulkarni, & Bamford, 2007).
Lastly, VR-based interventions afford therapists control over the virtual environment, enabling them to guide a client through a series of experiences wherein they can learn to modify, habituate, or substitute more adaptive cognitive or behavioral responses. As an alternative to in vivo experiences, VR is particularly attractive because it allows for regulated trials of behavioral or cognitive techniques and provides a new tool to monitor and develop self-efficacy overtime.
This paper will explore each of these affordances within the context of non-suicidal self-injury. I will provide a brief overview of virtual reality and non-suicidal self-injury. Then, I will delve into the affordances mentioned above. Finally, I will conclude with a reflection on the role of translational research in VR studies, and research on technology more generally.
Virtual Reality - In Brief
In the context of mental health, the two most common therapies in virtual reality are: Virtual Reality Exposure Therapy (VRET) and Virtual Reality Experiential Cognitive Therapy (VR-ECT). The objective of exposure, or cue, therapy is to introduce a triggering stimulus in a safe environment where an individual can more fully process emotions and diffuse maladaptive responses related to that stimulus (Rizzo, Pair, Graap, Manson, McNerney, Wiederhold & Spira, 2006). When experiencing arousal or reactivity in response to a stimulus, a therapist will typically monitor an individual as they become accustomed and desensitized to the stimulus over time. This type of intervention is common for individuals with post-traumatic stress disorder (PTSD). Clinicians also guide individuals through cognitive and behavioral techniques to help to individuals recognize the physiological signals that accompany arousal and rehearse new coping skills to self-moderate these states (Riva et al., 2016, p. 8). While these techniques mentioned are not novel, the advent of virtual environments provides novel ways to address and overcome some important limitations to current evidence-based treatment and experiment with new protocols (Carvalho, Freire, & Nardi, 2010).
One of the most unique affordances of VR technology is its capacity to produce a believable simulated environment and induce a sense of presence. Presence has been defined in multiple ways but in the simplest form it is “the feeling of being in a real and virtual space” or the “perceptual illusion of non-mediation” (Riva et al., 2015, p. 542; Lombard & Ditton, 1997, p. 9). This affordance of the technology offers a nice alternative to, or replacement for, in vivo exposure therapy because virtual environments are easier to control and they allow the clinician to experiment with different stimuli, which gives them a more precise understanding of an individual’s specific vulnerabilities.
In addition to work on PTSD, virtual reality exposure therapy (VRET) has been used as an efficacious intervention for other common mental illnesses including: substance use disorders (Bordnick, Carter, Traylor, 2011; Hone-Blanchet, Wensing, Fecteau, 2014; Bordnick, Traylor, A., Copp, Graap, Carter, Ferrer, & Walton, 2008) and anxiety disorders including phobias and generalized anxiety disorder (Powers & Emmelkamp, 2008; Opriş, Pintea, García‐Palacios, Botella, Szamosközi, & David, 2012).
The second therapeutic method employed in VR is Experiential Cognitive Therapy. This therapeutic intervention is guided by the tenets of embodied cognition and essentially rearranges an individual’s sensory input in order to give the illusion of presence in a distal environment. By manipulating visual and tactile cues, VR is capable of manipulating the first and third person perspectives in order to allow individuals a different experience of their body (Riva et al., 2015). For example, experiential cognitive therapy has been employed to induce perceptions of fake limbs in the case of phantom limb disorder (Perez-Marcos, Slater, & Sanchez-Vives, 2009), to understand out of body experiences (Leggenhager, Tadi, Metzinger, & Blanke, 2007), and to re-engage dysfunctional body image distortions among individuals with eating disorders (Gutiérrez-Maldonado, Wiederhold, & Riva, 2016; Riva, Bacchetta, Baruffi, & Molinari, 2001; Ferrer-García, & Gutiérrez-Maldonado, 2012),
A comprehensive review of the literature on VR in mental health is outside of the scope of this paper, however there are such reviews elsewhere (Valmaggia, Latif, Kempton, & Rus-Calafell, 2016). While the potential scope of virtual reality’s utility is still unknown, in the context of mental health many controlled trials provide evidence for the efficacy of VR in the treatment of psychopathology. The purpose of this paper moving forward will be to explore the potential of VR in enhancing our understanding of the etiology of, and potential treatment methods for, non-suicidal self-injury.
Non-suicidal self-injury, or “the deliberate destruction of body tissue without suicidal intent,” is increasingly prevalent among today’s youth and adolescents. In a 2013 study of high school students, 27.7% of the sample reported having engaged in NSSI in the last year (Gonzales & Bergstrom, 2013). A meta-analysis published a year later estimated that 20% of American youth have engaged in self-injury at some point their lives (Swannell, Martin, Page, Hasking, & St. John, 2014). These numbers are startling because self-injurious behaviors (SIB) are stigmatized and often openly discussed and because self-injury correlates with increased suicide risk (Whitlock, Muelenkamp, Eckenrode, Purington, Abrams, Barriera, & Kress, 2013; Muhlenkamp & Kerr, 2010).
Several therapeutic interventions have had varying degrees of success in mitigating self-injury behavior (e.g. CBT, DBT) however; efforts towards an effective treatment are hindered by the complex etiology of the disorder (Muehlenkamp, 2006).Self-injury behaviors can “arise from a number of motives, and at the same time fulfill several apparently distinct functions” (Horne & Csipke, 2009, p. 656). For example, at times individuals engage in self-harm to bring about or take away emotions, intense feelings and feelings of dissociation (Horne & Csipke, 2009, p.655). In response to a qualitative survey inquiring about NSSI behaviors, Horne and Csipke (2009) found that feeling too much and, paradoxically, not feeling enough were two of the most salient themes to come from their interviews with individuals who have self-injured.
Despite the inherent complexity of NSSI, one particularly salient characteristic of SIB is its function in regulating emotions. Individuals who engage in NSSI often describe the impetus of such behavior as related to difficulties in managing emotion, confusion about the nature of an emotion, or feelings of overwhelm that result in an unpleasant body-based feeling (e.g. agitation, anxiety) needing resolve. Current treatment methods most often focus on cognitive reframing and coping strategies like distress tolerance, emotion regulation, and mindfulness techniques (Muehlenkamp, 2012; Brausch & Muehlenkamp, 2014) delivered in both group and dyadic settings.
In addition to cognitive and behavioral strategies, a robust body of literature suggests that integrative body-oriented techniques may also be beneficial in NSSI treatment. Body regard is defined as “one’s protective attitudes, actions, and feelings towards the body” (Muehlenkamp, 2012, p. 332). This includes perceived physical and sensorimotor functioning and one’s “connection to, ownership of, and understanding of the body” (Muehlenkamp, 2012, p. 332). Conversely, body disregard, most often associated with eating disorders, is theorized to play an important role in NSSI. Numerous studies have supported this proposition, such that individuals with NSSI report high levels of body objectification, dissociation, and body disregard (Muehlenkamp, 2012, p. 333; Favaro et al., 2007; Nelson & Muehlenkamp, 2012). Furthermore, research shows that individuals who self-injure typically have high pain tolerance and poor interoceptive capacities (Muelenkamp, 2012). Interestingly, Dialectical Behavior Therapy (DBT) incorporates elements of body-centered attention through the program’s mindfulness techniques (Muehlenkamp, 2012). While body-oriented technique may not be the chief priority in DBT, some scholars suspect that part of program’s success in treating SIB may lie in its focus on body regard by proxy of mindfulness.
In sum, there has been progress in NSSI treatment over the years but not enough to mitigate clinicians’ concerns as it is still frequently considered a public health issue (Klonsky, 2011). The techniques discussed thus far offer individuals cognitive and behavioral tools and perhaps a better understanding of their own SIB but actually drawing upon these new coping strategies and abstaining from self-injurious behaviors outside of the therapists’ office remains challenging. Self-injury is often prompted by certain environmental triggers and is seen as a quick and effective method to down-regulate emotional arousal. Proving that a coping strategy can be as efficacious as self-injury is a key factor in achieving sustained behavior change.
The role of self-efficacy in behavior change
Bandura asserted that behavior change is mediated by perceived self-efficacy or an “individuals’ personal evaluations about their capacity to exercise control over events or to perform particular behaviors are a central mechanisms of personal agency” (1989; DiClemente, Carbonari, Montgomery, & Hughes, 1992). Within the context of mental illness, self-efficacy has a crucial role in affect regulation. Research suggests that self-efficacy moderates reactions among individuals with phobias (Muris, 2002, p. 338) and reduces temptation among individuals with addictive disorders (DiClemente et al., 1992). Furthermore, is possible to observe changes in self-efficacy among individuals’ with addictions upon exposure to their chosen drug and in individuals who are in recovery; therefore it is not a static phenomenon (DiCemente et al., 1992).
Bandura asserted that efficacy was a product of (1) performance mastery (2) vicarious experience, (3) verbal persuasion, and (4) physiological states of arousal (DiClemente et al., 1992 p. 141). Treatments for various disorders often engage with at least one of these four components. Interestingly, in one of Bandura’s original studies he explored all four aspects of self-efficacy in separate therapeutic conditions and found that there was no difference between the outcomes of these techniques. In all four conditions participants reported improved self-efficacy and subsequent behavioral control improved (Bandura, 1982, p .127).
Individuals who self-harm regularly report low levels of self-efficacy. Improving an individual’s competence in coping strategies, their belief in the efficacy of their coping strategy, and their ability to invoke this strategy in the real world, is of vital importance in NSSI treatment. Virtual reality may play a crucial role in bridging the gap between in session and real life coping strategies through repetitions of performance mastery, for example and ultimately increase and sustain self-efficacy.
Interventions in Virtual Reality
Virtual reality has several potential applications in the treatment of nonsuicidal self-injury. As previously mentioned, virtual reality has the ability to create strong visuals in fully immersive environment. This visual element is important because research has shown that visuals are powerful inducers of emotion (Riva, 2005) and emotion regulation is often a chief concern for individuals with self-injurious tendencies. Second, virtual reality is an embodied technology. Given the seeming importance of the body in both understanding and regulating emotions, treatments that attend to interoception and body intuition appear to have promise. And, finally, virtual reality provides a safe alternative to in vivo exposure, and is conducive to all four sources of self-efficacy. I will discuss each of these affordances and their application to possible NSSI interventions below. In addition to demonstrating the utility of VR, I want to emphasize the theoretical rationale for prioritizing research on the development of self-efficacy and body-oriented therapy in NSSI treatment.
Visual Immersion and Experience of Emotions
Clinicians have employed visuals to elicit emotions in practice for decades. Mental imagery, or imaginal exposure, is often used as a technique to the habituation and extinction of responses to triggering stimuli in cases of post-traumatic stress disorder (Nacasch, Foa, Fostick, Polliack, Dinstein,..Zohar, 2007), anxiety disorders (Krijn, Emmelkamp, Olafsson,& Biemond, 2004), obsessive-compulsive disorder (Abramowitz, Franklin & Foa, 2002), and generalized anxiety disorder (Ji et al., 2016, p. 710). In imaginal exposure, an individual is asked to imagine a scenario that is likely to evoke an undesirable emotion; then, a therapist assists the individual in processing and down-regulating their emotional arousal. Although mental imagery has been effective, its success is contingent upon an individuals’ ability to produce vivid mental imagery—an ability that is not static and differs from individual to individual (Carvalho, Freire, & Nardi, 2010). Moreover, physiological responses are integral to the experience and identification of emotions, and they too are dependent on “how vividly an individual can generate mental imagery in general” (Ji et al., 2016, p. 712). Virtual reality has been employed to overcome the limitations of imaginal exposure and so far it has been quite efficacious (Maltby et al., 2002).
In addition to enhancing visualization more generally, clinicians can design individually tailored virtual environments. A large focus of VR exposure therapy (VR-EBT) has been on posttraumatic stress disorder. PTSD involves symptoms such as frequent flashbacks, psychological distress and anxiety in response to environmental cues corresponding to past traumatic events (Botella, Serrano, Banos, & Garcia-Palacios, 2015). As such, prolonged exposure is often the go-to treatment method. Several studies have validated the efficacy of VR-EBT for PTSD (Miyahira, Folen, Hoffman, Garcia-Palacios, Spira, & Kawasaki, 2012; Ready, Gerardi, Backscheider, Mascar, & Rothbaum, 2010). In one study individuals with a history of abuse, criminal assault, or serious vehicle accidents, VR-EBT was as effective as traditional CBT, but at follow-up symptoms associated with PTSD remained low only for the VR condition (Botella et al. 2015, p. 2538; Banos, Guillen, Quero, Garcia-Palacios, Alcaniz & Botella, 2011). Similarly, in a study conducted in 2014, participants with PTSD were divided among a VR-EBT, a traditional imaginal exposure treatment, or a control (Roy, Costanzo, Blair, & Rizzo, 2014). Results confirmed the effectiveness of VR-EBT in contrast to traditional imaginal exposure such that individuals in the VR condition showed reduced PTSD scores, but the control and imaginal exposure condition did not. The mechanisms by which these differences occur are not well understood, however the vivid imagery and presence afforded through VR are likely to contribute to reduced symptomology.
Finally, a study conducted by Malbos, Rapee and Kavakli focused on parsing out the effect of VRET in contrast to VRET with a cognitive therapy component. Both groups received eight sessions of VRET for roughly 50 minutes each during which physiological, behavioral, and self-report measures were taken. Results showed no differences in group outcomes. Individuals in both treatment groups experienced increased mood, less anxiety and avoidance behavior, and reduced fear towards agoraphobic situations and cognitions (Malbos et al., 2012, p. 166). These results suggest that cognitive therapy did not significantly contribute to improved outcome. Results were maintained at 3-month follow-up. In sum, research enhanced imagery in VR exposure therapies has provided fairly consistent results.
Despite the success of VR-based exposure in the treatment of other disorders, in the context of self-injury, this work has been limited. There is some literature to suggest that exposure with response prevention (ER-P), a treatment focused on counterconditioning and extinction, is an effective therapeutic technique for NSSI (Kamen, 2009). A study conducted by Harned, Korslund, Foa, and Linehan (2014) found that DBT with a prolonged exposure element was superior to traditional DBT for individuals with co-occurring PTSD, BPD and self-injury though it was not possible to discern the effects on each disorder separately.
Given the prior research on the efficacy of VR exposure therapy in other emotion and mood disorders, it is reasonable to believe VR can serve a similar function in NSSI treatment. It is possible to imagine elicit an emotion-state similar to what a patient describes as preceding an episode of self-injury, then provide a new experience/coping strategy in place of self-injury, and work with these individuals to effectively down regulate said emotion. One reason exposure therapy may not be common for NSSI is that triggers often vary significantly from person to person. This, however, may provide further support for using VR over imaginal or in vivo exposure because it is relatively easy to design virtual environments to fit with an individual’s specific triggering scenario or context.
Embodiment and Body Experience
Virtual [can be described as] an embodied technology for its ability of modifying presence: the human operator can experience the synthetic environment as if it were ‘his /her surrounding world’ (incorporation) or can experience the synthetic avatar as if it were ‘his/her own body’ (incarnation). (Riva, Dakanalis, & Mantovani, 2015, p. 536)
In line with the tradition of embodied cognition, Riva and colleagues argue that, “the mind can only be understood in the context of its relationship to a physical body that interacts with the world” (2015, p. 530). This means that by altering how one interacts with the environment through sensory experiences (visual, haptic, olfactory) we can alter the experience of the body as the above quote clearly describes (Riva, Dakanalis, & Mantovani, 2015, p. 530).
This technique has been utilized in controlled clinical trials for eating disorders (Ferrer-Garcia, Gutierrez-Maldonado, & Riva, 2013; Ferrer-Garcia, Gutierrez-Maldonado, 2012) and rehabilitation with phantom limb disorder (Perez-Marcos, Slater, & Sanches-Vives, 2009). An interesting application of VR is in treating allocentric lock. Allocentric Lock Hypothesis states that individuals with distorted body relations are often locked into a negative observer’s perspective (e.g. third person perspective) of their body (Riva et al, 2015). Intrinsic features of VR bring individuals into contact with stored, “unconscious information about their body schemata” and make distortions between the virtual environment and the individual’s proprioceptive system more apparent (Ferrer-Garcia & Gutierrez-Maldonado, 2012, p. 5). In a therapeutic setting, psychotherapists are able to call attention to body distortion by combining elements of cognitive behavior therapy with reflections on perceptual or sensorimotor processes in the virtual environment. In turn, this body-based experience can increase body awareness and free an individual from drawing upon allocentric, maladaptive mental schema (Riva, 2011).
Furthermore, some research suggests that results of body-based VR interventions endure for quite some time. Riva and colleagues conducted a study on morbidly obese individuals comparing a VR-based experiential cognitive therapy with both traditional nutrition and cognitive behavior therapy (Riva, Castelnuovo, Cesa, Gagglioli, Matovani & Molinari, 2012). The researchers found that individuals in the VR condition participants lost more weight and this weight-loss was maintained at a one-year follow-up (Riva, Dakanalis, & Mantovani, 2014). The loss was not maintained in either nutrition or cognitive-behavior therapy.
While a majority of the work on embodiment in VR has focused on eating and body image disorder, anxiety and phobic disorders also benefit from this affordance. Viaud-Delmon, Berthoz and Jouvent (2002) note that individuals use their body as a framework to interpret emotion, much like SIB.
As mentioned research suggests that body dissatisfaction and poor interoceptive awareness are salient characteristics of NSSI which should be unsurprising considering that self-harm often co-occurs with eating disorders and the act of harm itself is an assault on one’s body (Brausch & Muelhenkamp, 2014, p. 244; Favaro & Santonastaso, 1998). Virtual reality could help individuals reconnect with their body and improve interoceptive awareness. Some individuals with SIB have difficulty recognizing and attributing emotional and physiological states with the appropriate catalyst. This interoceptive disconnect may exacerbate emotional confusion. That is, when an individual responds to a frightful stimulus their nervous system activates and they experience physiological changes such as increased heart rate and skin conductance. Without being in tune with these signals, the corresponding emotion (fear) may seem particularly threatening or to come out of nowhere (Muehlenkamp, 2012).
By closely monitoring an individual’s physiological response to triggering stimuli within a virtual environment a therapist can assist an individual in identifying the catalyst and becoming more aware of their response and familiar with how their reaction feels in their body. This awareness may help individuals understand the relationship between their emotions and physiological response. VR also provides the possibility of observing reactions to triggering stimuli from both a first and third person perspective. Therefore, an individual can begin to explore interoception vicariously in the virtual environment and slowly progress to a more intense first person perspective.
Similarly, VR may help promote body integrity “one’s sense of connection to, ownership of, and understanding of the body” (Muehlenkamp, 2012, p. 332). One’s connection to their body is important in SIB because it has been suggested that body disregard, or disgust, leads to poor body protection (Brausch & Muehlenkamp, 2014). Furthermore, poor awareness of the body’s physiological functioning has been associated with higher pain thresholds and may contribute to more serious injury or suicide (Brausch & Muehlenkamp, 2014, p. 245).
Ecologically Validity, Repetition, and Self-Efficacy
Finally, virtual reality allows treatment delivery in a controlled and ecologically valid environment. A common difficulty in therapies that rely on training individuals to use new coping strategies is that there is a gap between in-session training and real-life scenarios.
VR provides the scientist/clinician full control over the virtual environment and an opportunity to capture measures that may be useful in identifying the success of such therapy.
As part of treatment, clinicians often recommend that patients compile a list of alternative coping strategies to draw from when they experience the urge to self-harm. However, engaging in activities on the list when an urge arises can be quite challenging, especially for individuals in early stages behavior change (Prochaska & DiClemente, 1986). Often the issue is not that individuals do not know of other coping strategies but that they find it difficult to execute in times of vulnerability or they haven’t found one that provides the same effect as SI.
One way to take advantage of VR technologies may be guide individuals into a state of arousal and instruct them through a coping method that alleviates that arousal, without engaging in self-harm. When this is done multiple times, as in exposure therapy, an individual should habituate to the trigger through Bandura’s mastery experience—proof that they can abstain from self-injury and successfully employ other coping strategies (Riva & Wiederhold, 2002). Finally, Bandura noted that self-efficacy requires both behavioral and cognitive control in response to environmental threats. By practicing adaptive coping techniques in a controlled virtual environment an individual should gain increased self-efficacy. In fact, in a study by Krijn and colleagues (2004) multiple sessions of virtual reality exposure therapy (VRET) was able to increase self-efficacy among individuals with anxiety disorders (Krijn, Emmelkamp, Olafsson & Biemond, 2004).
In sum, virtual reality interventions seem to be an intriguing prospect for individuals with NSSI. VR therapies would allow them to experience arousing situations where complicated emotions may arise individuals can practice new coping strategies aimed at emotion regulation. This strategy has already been effective in treatments with PTSD, substance use, and anxiety disorders. Experiencing an urge in a safe environment and refraining from acting on it behaviorally may build self-efficacy and healthier mental patterns for individuals who engage in NSSI. In addition to the exposure and experiential therapies discussed here, VR can support trials of existing programs as well. As promising case study employed VR to deliver a combination of mindfulness and dialectical-behavior therapy for the treatment of NSSI (Nararro-Haro, Hoffman, Garcia-Palacios, Sampaio, Alhalabi, Hall, & Linehan, 2016). Researchers found that the treatment reduced “urges to commit suicide, self-harm, quit therapy, use substances and negative emotions” (Nararro-Haro et al., 2016).
Translational research and future of VR in Mental Health
The research that I have discussed in this paper is almost entirely produced by randomized controlled trials or case studies. I have highlighted the potential efficacy of VR in treating self-injury but I have not yet discussed the translational component of this research. The biggest challenge for translational research in the domain of technology-based interventions for mental health is the rate at which new technologies turn over. There is a large disparity in the rate of academic research and the rate of technological development. To address this gap, social and behavioral scientists must understand the cognitive and behavioral mechanisms that propel change and develop theoretical models that speak to multiple stakeholders.
As an example, Naslund and colleagues (2017) recently discussed the Behavioral Intervention Technology Model (BITM). The researchers contend that the BITM is able to provide a comprehensive framework that translates the role of a technology from the conceptual level, through development and delivery (Naslund et al., 2017, p. 5). This model considers behavioral components, intervention characteristics, technical design, (e.g. interface development, software) and clinical objectives.
To use the model properly, however researchers from many different disciplines (e.g. computer science, clinical science, social science) must collaborate. Historically, interdisciplinary collaboration has proven difficult in the academy. Epistemological and axiological assumptions vary between departments and funding opportunities often influence research agendas. Research centers like The Center for Behavioral Intervention Technologies at Northwestern University provide a nice example of the potential of collaboration and the vital role of translational research. In these centers scholars with different expertise have come together with the common goal of advancing technology in the domains of mobile mental health. These institutions rely upon translational research because the success of their products and trials depend on their ability to communicate science to technologists and technological affordances to clinicians, and so on.
Similarly, Wethington and colleagues write that translational research involves applying scientific theory to design and development. Most importantly “the findings from the intervention then translate back for the development of better theory and –even more importantly—research more informed by the public and of demonstrated public health impact” (Wethington, Herman, & Pillemer, 2012, p. 10). To this end, results generated from the BITM or any other study of technology should keep as a chief priority how the technology helps the individual in need and how it can generate new knowledge about self-injury more generally. One area of research that is still poorly understood is the etiology of dissociative and emotion regulatory characteristics in self-injury. Studies focusing on similarities or differences in physiological arousal and emotional experiences while under stress may help us understand what appears to be two distinct types of SI.
A final translation element worth mentioning is the gap between what the public knows of cutting edge technology, like VR, and what it can actually do. Common conceptions of VR decades ago may have been limited to science fiction, and even today they remain primarily rooted in the entertainment industry. However, as highlighted here, VR is becoming an influential modality for interventions in the realm of physical rehabilitation and mental health. The technology can serve both functions, and likely others, but in order to make people aware of the potential for VR to assist in treatment for pervasive health issues will require careful planning and framing. There is a common misconception that VR requires full immersion. As technology advances, we will continue to see more accessible forms of VR on the market making it a feasible option not only in the lab or clinical contexts, but at home as well. In fact, preliminary studies show that full immersion isn’t always necessary for symptom improvement (Gutiérrez-Maldonado, Wiederhold, & Riva, 2016). The more important element is that content is “emotionally engaging,” vivid, and relevant (Gutiérrez-Maldonado, Wiederhold, & Riva, 2016, p. 151). As scientists it is our responsibility to be transparent about the social impact of our work and translation is a vital component.
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 Interoceptive awareness has been defined as “an individual’s awareness of their own physiological functioning or the extent to which an individual is aware of their body’s sensations and cues” (Brausch & Muelenkamp, 2014, p. 14; Muehlenkamp, 2012, p. 239).
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