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Abstract Automated delivery of therapy in virtual reality (VR) has the potential to be used for smoking cessation. Most obviously, it could be used to practise and establish alternative reactions to smoking cues. The first step in treatment development is to show that VR environments can trigger sufficient cravings in smokers. We evaluated a new VR public house outdoor scenario with 100 individuals who smoked daily. Participants were randomly assigned to the VR scenario with smoking cues or a neutral experience in VR. The VR experiences were presented in a standalone VR headset. Before and after VR, we collected self-reported craving scores for cigarettes and alcohol using the Tobacco Craving Questionnaire (TCQ) and visual analogue scales (VAS). Physiological data were also collected. Compared to the neutral condition, exposure to the smoking cues led to a large increase in craving for a cigarette (TCQ β = 11.44, p

Abstract Virtual reality (VR) is increasingly used in the study and treatment of paranoia. This is based on the finding that people who mistakenly perceive hostile intent from other people also perceive similar threat from virtual characters. However, there has been no study of the programming characteristics of virtual characters that may influence their interpretation. We set out to investigate how the animation and expressions of virtual humans may affect paranoia. In a two-by-two factor, between-groups, randomized design, 122 individuals with elevated paranoia rated their perceptions of virtual humans, set in an eye-tracking enabled VR lift scenario, that varied in facial animation (static or animated) and expression (neutral or positive). Both facial animation (group difference = 102.328 [51.783, 152.872], p

AbstractVirtual reality (VR) is an immersive technology in which delivery of psychological therapy techniques can be automated. Techniques can be implemented similarly to real-world delivery or in ways that are not possible in the real world to enhance efficacy. The potential is for greater access for patients to effective therapy. Despite an increase in the use of VR for mental health, there are few descriptions of how to build and design automated VR therapies. We describe the development of Phoenix VR Self-Confidence Therapy, designed to increase positive self-beliefs in young patients diagnosed with psychosis in order to improve psychological well-being. A double-diamond, user-centered design process conducted over the course of 18 months was used, involving stakeholders from multiple areas: individuals with lived experience of psychosis, clinical psychologists, treatment designers, and VR software developers. Thirteen meetings were held with young patients diagnosed with psychosis to increase the understanding and improve the assessment of positive self-beliefs, help design the scenarios for implementing therapeutic techniques, and conduct user testing. The resulting Phoenix therapy is a class I United Kingdom Conformity Assessed (UKCA)–certified medical device designed to be used on the standalone Meta Quest 2 (Meta Platforms) headset. Phoenix aims to build up 3 types of positive self-beliefs that are connected to psychological well-being. In a community farm area, tasks are designed to increase a sense of mastery and achievement (“I can make a difference”); in a TV studio, users complete an activity with graded levels of difficulty to promote success in the face of a challenge (“I can do this”); and in a forest by a lake, activities are designed to encourage feelings of pleasure and enjoyment (“I can enjoy things”). Phoenix is delivered over the course of approximately 6 weekly sessions supported by a mental health provider. Patients can take the headsets home to use in between sessions. Usability testing with individuals with lived experience of psychosis, as well as patients in the National Health Service (aged 16‐26 years), demonstrated that Phoenix is engaging, easy to use, and has high levels of satisfaction.

Abstract We set out to test whether positive non-verbal behaviours of a virtual coach can enhance people's engagement in automated virtual reality therapy. 120 individuals scoring highly for fear of heights participated. In a two-by-two factor, between-groups, randomised design, participants met a virtual coach that varied in warmth of facial expression (with/without) and affirmative nods (with/without). The virtual coach provided a consultation about treating fear of heights. Participants rated the therapeutic alliance, treatment credibility, and treatment expectancy. Both warm facial expressions (group difference = 7.44 [3.25, 11.62], p = 0.001, $${eta}_{p}^{2}$$ eta p 2 =0.10) and affirmative nods (group difference = 4.36 [0.21, 8.58], p = 0.040, $${eta}_{p}^{2}$$ eta p 2 = 0.04) by the virtual coach independently increased therapeutic alliance. Affirmative nods increased the treatment credibility (group difference = 1.76 [0.34, 3.11], p = 0.015, $${eta}_{p}^{2}$$ eta p 2 = 0.05) and expectancy (group difference = 2.28 [0.45, 4.12], p = 0.015, $${eta}_{p}^{2}$$ eta p 2 = 0.05) but warm facial expressions did not increase treatment credibility (group difference = 0.64 [− 0.75, 2.02], p = 0.363, $${eta}_{p}^{2}$$ eta p 2 = 0.01) or expectancy (group difference = 0.36 [− 1.48, 2.20], p = 0.700, $${eta}_{p}^{2}$$ eta p 2 = 0.001). There were no significant interactions between head nods and facial expressions in the occurrence of therapeutic alliance (p = 0.403, $${eta}_{p}^{2}$$ eta p 2 = 0.01), credibility (p = 0.072, $${eta}_{p}^{2}$$ eta p 2 = 0.03), or expectancy (p = 0.275, $${eta}_{p}^{2}$$ eta p 2 = 0.01). Our results demonstrate that in the development of automated VR therapies there is likely to be therapeutic value in detailed consideration of the animations of virtual coaches.

Abstract Virtual reality (VR) affords the study of the behaviour of people in social situations that would be logistically difficult or ethically problematic in reality. The laboratory-controlled setup makes it straightforward to collect multi-modal data and compare the responses across different experimental conditions. However, the scenario is typically fixed and the resulting data are usually analysed only once the VR experience has ended. Here we describe a method that allows adaptation of the environment to the behaviours of participants and where data is collected and processed during the experience. The goal was to examine the extent to which helping behaviour of participants towards the victim of a violent aggression might be encouraged, with the use of reinforcement learning (RL). In the scenario, a virtual human character represented as a supporter of the Arsenal Football Club, was attacked by another with the aggression escalating over time. (In some countries football is referred to as ‘soccer’, but we will use ‘football’ throughout). Each participant, a bystander in the scene, might intervene to help the victim or do nothing. By varying the extent to which some actions of the virtual characters during the scenario were determined by the RL we were able to examine whether the RL resulted in a greater number of helping interventions. Forty five participants took part in the study divided into three groups: with no RL, a medium level of RL, or full operation of the RL. The results show that the greater extent to which the RL operated the greater the number of interventions. We suggest that this methodology could be an alternative to full multi-factorial experimental designs, and more importantly as a way to produce adaptive VR scenarios that encourage participants towards a particular line of action.

Abstract Paranoia may build on negative beliefs held both about the self and others. Compassionate imagery may be one way of reducing such negative beliefs, and hence paranoia. Two studies tested this idea, one targeting compassion for the self and one targeting compassion for others. Two-hundred individuals from the general population scoring highly for paranoia were recruited. The studies used a randomised controlled experimental design, with embedded tests for mediation. Study one targeted self-compassion via creation of a compassionate coach (CC) image. Study two targeted compassion for others via loving kindness meditation (LKM). Individuals repeatedly entered neutral virtual reality social environments. Changes in compassion and paranoia were assessed. Compared to controls, the CC group increased in self-compassion (group difference = 2.12, C.I. = 1.57;2.67, p =

Traditional work on bystander intervention in violent emergencies has found that the larger the group, the less the chance that any individual will intervene. Here, we tested the impact on helping behavior of the affiliation of the bystanders with respect to the participants. We recruited 40 male supporters of the U.K. Arsenal football club for a two-factor between groups study with 10 participants per group. Each participant spoke with a virtual human Arsenal supporter (V), the scenario displayed in a virtual reality system. During this conversation, another virtual character (P), not an Arsenal fan, verbally abused V for being an Arsenal fan leading eventually to physical pushing. There was a group of three virtual bystanders who were all either Arsenal supporters indicated by their shirts, or football fans wearing unbranded shirts. These bystanders either encouraged the participant to intervene or dissuaded him. We recorded the number of times that participants intervened to help V during the aggression. We found that participants were more likely to intervene when the bystanders were out-group with respect to the participant. By comparing levels of intervention with a “baseline” study (identical except for the presence of bystanders), we conclude that the presence of in-group bystanders decreases helping. We argue therefore that, other things being equal, diffusion of responsibility is more likely to be overcome when participant and victim share group membership, but bystanders do not. Our findings help to develop understanding of how diffusion of responsibility works by combining elements of both the bystander effect and the social identity approach to bystander behavior.

Handheld and wearable devices are becoming ubiquitous in our lives and augmented reality technology is stepping out of the laboratory environment and becoming ready to be used by anyone with portable devices. The success of augmented reality applications for pedestrians depends on different factors including a reliable guidance system and preventing risks. We show that different guidance systems can be supplementary to provide directions to a point of interest and offer clues that help the user find the augmented data when they get close to the location they have to visit. We tested the helpfulness of a map with the points of interest, an image preview of the next point of interest to visit, and an arrow showing the direction to it. The results show that the effectiveness of these guidance systems depend on the distance to the point of interest and the accuracy of the data obtained from the Global Positioning System. We also measured the total time that participants spent looking at the screen, as well as the perceived elapsed time as a measurement of real world dissociation. Finally, we discuss preliminary results to minimize the risk of accidents when using augmented reality applications in an outdoor urban environment.

Introduction Many patients with psychosis experience everyday social situations as anxiety-provoking. The fears can arise, for example, from paranoia, hallucinations, social anxiety or negative-self beliefs. The fears lead patients to withdraw from activities, and this isolation leads to a cycle of worsening physical and mental health. Breaking this cycle requires highly active treatment directly in the troubling situations so that patients learn that they can safely and confidently enter them. However patients with psychosis seldom receive such life-changing interventions. To solve this problem we have developed an automated psychological treatment delivered in virtual reality (VR). It allows patients to experience computer simulations of the situations that they find anxiety-provoking. A virtual coach guides patients, using cognitive techniques, in how to overcome their fears. Patients are willing to enter VR simulations of anxiety-provoking situations because they know the simulations are not real, but the learning made transfers to the real world.Methods and analysis 432 patients with psychosis and anxious avoidance of social situations will be recruited from National Health Service (NHS) secondary care services. In the gameChange trial, they will be randomised (1:1) to the six-session VR cognitive treatment added to treatment as usual or treatment as usual alone. Assessments will be conducted at 0, 6 (post-treatment) and 26 weeks by a researcher blind to allocation. The primary outcome is avoidance and distress in real-life situations, using a behavioural assessment task, at 6 weeks. The secondary outcomes are psychiatric symptoms, activity levels and quality of life. All main analyses will be intention-to-treat. Moderation and mediation will be tested. An economic evaluation will be conducted.Ethics and dissemination The trial has received ethical approval from the NHS South Central - Oxford B Research Ethics Committee (19/SC/0075). A key output will be a high-quality automated VR treatment for patients to overcome anxious avoidance of social situations.Trial registration number ISRCTN17308399.

Background Self-criticism is a ubiquitous feature of psychopathology and can be combatted by increasing levels of self-compassion. However, some patients are resistant to self-compassion. Aims To investigate whether the effects of self-identification with virtual bodies within immersive virtual reality could be exploited to increase self-compassion in patients with depression. Method We developed an 8-minute scenario in which 15 patients practised delivering compassion in one virtual body and then experienced receiving it from themselves in another virtual body. Results In an open trial, three repetitions of this scenario led to significant reductions in depression severity and self-criticism, as well as to a significant increase in self-compassion, from baseline to 4-week follow-up. Four patients showed clinically significant improvement. Conclusions The results indicate that interventions using immersive virtual reality may have considerable clinical potential and that further development of these methods preparatory to a controlled trial is now warranted.

Augmented Reality (AR) superimposes computer graphics (CG) onto a user’s view of the real world. A key quality problem in this field is to achieve coherence between reality and CG when the user’s eyes refocus or change pupil size. We designed and evaluated a display that improves coherence by measuring the user’s eye state and continuously adapting CG accordingly. Our tabletop prototype emulates an Optical See-Through Head-Mounted Display, a common AR display device. In our evaluation, participants observed three pillars at different depths. We then challenged them to identify a virtual pillar among the three while freely refocusing their eyes. Results show that our design significantly improved realism. Compared to Light Field Displays, our design aims to simplify display-optics while providing similar quality. We could only partially achieve this goal. We discuss the lessons we learned and how we plan to overcome the remaining challenges. The experimental protocol from our evaluation is useful for display developers as it can be used to measure the coherence of a display.

Virtual reality has been successfully used to study and treat psychological disorders such as phobias and posttraumatic stress disorder but has rarely been applied to clinically-relevant emotions other than fear and anxiety. Self-criticism is a ubiquitous feature of psychopathology and can be treated by increasing levels of self-compassion. We exploited the known effects of identification with a virtual body to arrange for healthy female volunteers high in self-criticism to experience self-compassion from an embodied first-person perspective within immersive virtual reality. Whereas observation and practice of compassionate responses reduced self-criticism, the additional experience of embodiment also increased self-compassion and feelings of being safe. The results suggest potential new uses for immersive virtual reality in a range of clinical conditions.

Under what conditions will a bystander intervene to try to stop a violent attack by one person on another? It is generally believed that the greater the size of the crowd of bystanders, the less the chance that any of them will intervene. A complementary model is that social identity is critical as an explanatory variable. For example, when the bystander shares common social identity with the victim the probability of intervention is enhanced, other things being equal. However, it is generally not possible to study such hypotheses experimentally for practical and ethical reasons. Here we show that an experiment that depicts a violent incident at life-size in immersive virtual reality lends support to the social identity explanation. 40 male supporters of Arsenal Football Club in England were recruited for a two-factor between-groups experiment: the victim was either an Arsenal supporter or not (in-group/out-group), and looked towards the participant for help or not during the confrontation. The response variables were the numbers of verbal and physical interventions by the participant during the violent argument. The number of physical interventions had a significantly greater mean in the in-group condition compared to the out-group. The more that participants perceived that the Victim was looking to them for help the greater the number of interventions in the in-group but not in the out-group. These results are supported by standard statistical analysis of variance, with more detailed findings obtained by a symbolic regression procedure based on genetic programming. Verbal interventions made during their experience, and analysis of post-experiment interview data suggest that in-group members were more prone to confrontational intervention compared to the out-group who were more prone to make statements to try to diffuse the situation.

This paper reviews experimental methods for the study of the responses of people to violence in digital media, and in particular considers the issues of internal validity on the one hand and ecological validity or generalisability of results to events in the real world. Experimental methods typically involve a significant level of abstraction from reality, with participants required to carry out tasks that are far removed from violence in real life, and hence their ecological validity is questionable. On the other hand studies based on field data, while having ecological validity, cannot control multiple confounding variables that may have an impact on observed results, so that their internal validity is questionable. It is argued that immersive virtual reality may provide a unification of these two approaches. Since people tend to respond realistically to situations and events that occur in virtual reality, and since virtual reality simulations can be completely controlled for experimental purposes, studies of responses to violence within virtual reality are likely to have both ecological and internal validity. This depends on a property that we call ‘plausibility’ – including the fidelity of the depicted situation with prior knowledge and expectations. We illustrate this with data from a previously published experiment, a virtual reprise of Stanley Milgram’s 1960s obedience experiment, and also with pilot data from a new study being developed that looks at bystander responses to violent incidents.