Do conversations with virtual avatars increase feelings of social anxiety?

Highlights

• Current virtual reality (VR) technology does not permit conversation exposures.

• This study piloted new technology to compare VR versus in vivo conversations for social anxiety.

• Healthy participants (N = 26) reported higher fear but lower realism in the VR conversation condition.

• These pilot data are encouraging given fear activation is most important for effective fear reduction.

Abstract

Virtual reality (VR) technology provides a way to conduct exposure therapy with patients with social anxiety. However, the primary limitation of current technology is that the operator is limited to pre-programed avatars that cannot be controlled to interact/converse with the patient in real time. The current study piloted new technology allowing the operator to directly control the avatar (including speaking) during VR conversations. Using an incomplete repeated measures (VR vs. in vivo conversation) design and random starting order with rotation counterbalancing, participants (N = 26) provided ratings of fear and presence during both VR and in vivo conversations. Results showed that VR conversation successfully elevated fear ratings relative to baseline (d = 2.29). Participants also rated their fear higher during VR conversation than during in vivo conversation (d = 0.85). However, in vivo conversation was rated as more realistic than VR conversation (d = 0.74). No participants dropped out and 100% completed both VR and in vivo conversations. Qualitative participant comments suggested that the VR conversations would be more realistic if they did not meet the actor/operator and if they were not in the same room as the participant. Overall, the data suggest that the novel technology allowing real time interaction/conversation in VR may prove useful for the treatment of social anxiety in future studies.

Introduction

Social anxiety disorder (SAD) is a debilitating disorder that affects approximately 12% of the United States population (Kessler et al., 2005). Currently the most researched and effective treatment for SAD is exposure-based cognitive behaviour therapy (CBT) (Hofmann and Smits, 2008, Powers et al., 2008). However, given the feared situation in SAD involves interacting with or performing in front of other people, creating realistic exposure scenarios in clinical practice is challenging and not often achieved in clinical practice. Indeed, most therapists do not conduct any exposure therapy. For example, bibliotherapy, medication, dynamic therapy, and cognitive therapy are all more commonly used than exposure (Freiheit et al., 2004, Goisman et al., 1999). Among the few therapists that utilize exposure therapy, they often rely on prescribing exposures as homework (risking poor compliance) or, if time permits, meeting the patient at various locations to conduct exposure exercises. These methods come with increased cost, ethical concerns, and difficulty controlling stimuli. In response to these concerns, researchers have developed alternative methods of exposure delivery including over the internet and virtual reality exposure therapy (VRET) environments.

Anxiety treatment via the internet is helpful in reaching clients who may otherwise not have access to trained exposure therapists (Carlbring et al., 2006, Carlbring et al., 2007, Lange et al., 2000, Lange et al., 2001, Lange et al., 2003). However, exposure is still limited to email/texting, a webcam where the therapist still needs to recruit confederates to interact with, or an avatar that is not fully controlled in real time by the therapist. Exposure through virtual reality has proven quite successful across the anxiety disorders (Emmelkamp, 2005, Opris et al., 2012, Powers and Emmelkamp, 2008). A noteworthy benefit of using (VRET) is that it easily enables the therapist to manipulate the feared situation and environment for public speaking anxiety (Anderson et al., 2005, Safir et al., 2012, Wallach et al., 2009). In addition, VRET is considered more tolerable and acceptable to patients (Emmelkamp, 2005). Unfortunately, VRET technology does not yet allow the patient to have conversations with the people (avatars) in the virtual environments in real time. For example, it is possible to hear a voice over the internet while looking at an avatar. However, the avatar's lips and movements/gestures are not in sync with the voice. Trials to date have only included exposure to such avatars with limited response options and speech either through typing or auditory output without linked facial movement and expressions (Harris et al., 2002, Klinger et al., 2005). This is unfortunate given findings that show involvement in the VRET is crucial for success (Price, Mehta, Tone, & Anderson, 2011) and that involvement is enhanced when avatars are visually responsive to the participant (Garau, Slater, Pertaub, & Razzaque, 2005). Thus, interactive real-time conversations still need to be conducted in vivo; VRET would be far more useful for treating SAD if the therapist were able to also manipulate the avatar to converse with the patient in real time. This would allow therapists to conduct in-session exposure exercises aimed at reducing patients’ fears of performance situations involving social interaction and conversation.

Two recent studies piloted new virtual reality (VR) technology in the context of training women to resist unwanted sexual advances. Jouriles, McDonald, Kullowatz, Rosenfield, Gomez, and Cuevas (2009) randomized 62 undergraduate students to a standard face-to-face role-play with a male actor or a virtual conversation with a male avatar (fully controlled by the actor) in a virtual environment. Consistent with predictions, VR conversations were rated as more realistic and participants showed greater negative affect compared to the face-to-face condition. Similar findings were observed in the second study of 48 women randomized to VR or face-to-face conditions (Jouriles, Simpson Rowe, McDonald, Platt, & Gomez, 2011). Although preliminary, findings from these studies support the validity of virtual conversation for assessing undergraduate women's reactions in sexually threatening situations and underscore the potential utility of this VR technology for simulating social interaction situations. However, this technology has not yet been extended to the treatment of social anxiety. As a first step in this process, we tested the ability of this technology to elicit social anxiety in a college population.

This proof-of-concept pilot study investigated the use of VR interactive conversation technology in college populations. At this stage, we define “proof” as activation of the fear structure (operationalized as SUDs during VR conversation). Although we anticipated SUDs to be higher in the in vivo comparison condition, we wanted to see if VR conversation significantly raised SUDs relative to baseline. Participants discussed controversial topics with a actor/operator in either VR or in vivo environments. Based on previous findings (Barlow et al., 1969, Dyckman and Cowan, 1978, Emmelkamp and Wessels, 1975, Jouriles et al., 2009, Jouriles et al., 2011, Litvak, 1969, Powers and Emmelkamp, 2008, Sherman, 1972, Watson et al., 1973), we expected that: (a) SUDs would be significantly higher during VR conversation than at baseline, (b) participants would report higher anxiety during the in vivo conversation compared to the VR conversation, and (c) participants would rate the in vivo conversation as more realistic than the VR conversation.