Virtual Reality (VR) has become a key technology in our current digital society. Once merely featured in science fiction films, VR is now becoming increasingly popular in different domains of life like gaming, marketing, industrial training, and education.
However, despite its relatively recent rise to popularity, VR’s use in the medical sphere has a longer history. The first healthcare applications of VR started in the early ’90s due to the need of medical staff to visualize complex medical data, particularly during surgery and for surgery planning (Chinnock, 1994). During this initial period, other medical applications included surgical simulators for medical training, telepresence surgery, pain management, physical therapy and motor rehabilitation (Satava, 1995), and the treatment of mental health disorders (Botella et al., 2004).
As a result, after three decades of research, the use of VR as a therapeutic tool in the field of psychology has accumulated impressive scientific evidence on its utility for the assessment and treatment of a variety of psychological disorders and behavioral issues. Recent review and meta-analytic studies have shown that VR-based interventions can be an effective alternative to the most traditional cognitive-behavioral intervention tools for overcoming mental health disorders, mainly related to:
In the specialized literature the construct of presence is usually considered the principal mechanism by which VR is effective as a clinical intervention tool (Alsina-Jurnet & Gutiérrez-Maldonado, 2010). This term is related to the user’s illusion of being transported to a virtual environment, irrespective of her physical environment and without a relevant cognitive effort. One of the main consequences of this illusion is that the virtual scenario may evoke the same reactions, thoughts, and emotions as the experience in a real-world situation (Alsina Jurnet et al., 2011). Thus, for example, if an individual is exposed to peaceful, pleasant, non-arousing nature-based virtual scenarios, then they would experience feelings of relaxation, vitality, and restoration that are very similar to those experienced in physical natural environments (Mattila et al., 2020). The sense of presence in virtual environments helps to understand the restorative effects of VR, as well as its potential to promote a good emotional wellbeing in both clinical and non-clinical populations.
In a wider sense, the use of VR to promote relaxation, reduce stress, and restore work productivity is based on the Attention Restoration Theory (ART) (Kaplan, 2001). According to this theory, the tasks performed in our daily life require directed attention, where focusing on the task requires effort and cognitive resources. But those resources can be restored and improved by exposing us to situations that provide a psychological and emotional distance from our mental concerns (“being away” from our daily routine), combined with effortless, interest-driven attention (“fascination”), and supported by an environment of substantial scope (Anderson et al., 2017). Such experiences allow the mind to rest, thereby regaining its voluntary attention capacity, and relieving mental fatigue and stress (Ohly et al., 2016). According to this theory, the mechanisms that lead to mental restoration can be found in natural scenarios, while urban environments contribute to the depletion of directed attention (Kaplan, 1995). Urban environments contain a variety of stimuli (for ex.: lights, loud sounds, dynamic lights, etc.) that capture peoples’ attention while also requiring directed attention to overcome the stimuli (e.g., ignoring advertisements). As a result, urban scenarios are less restorative than natural environments as they draw the individual’s attention towards them as he or she attempts to overcome the stimuli (Berman et al., 2008).
The use of nature-based VR scenarios is also based on the Stress Recovery Theory (SRT) (Ulrich, 1983). SRT has its roots in evolutionary psychology and claims that because humans evolved during a long period in natural environments, people are psychologically and physiologically adapted to natural, as opposed to urban scenarios (Ulrich et al., 1991). According to this theory, nature-based environments aid in recovering from stress by inducing a positive affective state. The positive affective state is evoked because nature scenes comprise specific structural and visual properties (for ex.: complexity and depth) and a lack of perceived threat that cannot be found in urban scenarios (Ulrich, 1983). It is interesting to mention that in line with ART and SRT, several studies have shown that photographs (Brown et al., 2013; Gladwell et al., 2012), real locations (Miyazaki et al., 2014; Tsunetsugu et al., 2013) and VR scenarios of natural environments (Tanja-Dijkstra, et al., 2014; Schutte et al., 2017; Valtchanov and Ellard, 2010; Yu et al., 2018) have a more positive impact on individuals’ psychological wellbeing compared to photographs, real locations or VR scenarios of urban environments.
Specifically in relation to nature-based VR, there is now scientific evidence that suggests that the exposure to immersive natural scenes is effective in reducing stress and promoting a positive mood in the general population. In particular, although more research is still needed, current studies suggest that the use of natural virtual scenarios like a tropical beach (Anderson et al., 2017; Blum et al., 2019), outdoor forest settings (Annerstedt et al., 2013; Browning et al., 2020; Chan et al., 2021; Rockstroh et al., 2020; Valtchanov & Ellard, 2010; Wang et al., 2019, Yu et al., 2018), underwater environments (Liszio et al., 2018), a river (Navarro Haro et al., 2017), a meadow (Schutte et al., 2017), a wilderness park (Villani & Riva, 2012) or a tropical island (Villani & Riva, 2007) support and promote relaxation, stress restoration and a positive mood. In addition, the use of natural VR scenarios has been shown to activate the parasympathetic system, which facilitates mood regulation and stress recovery (Valtchanov et al., 2010).
These studies summarize the benefits and effectiveness of nature exposure via virtual environments. Immersive technologies like VR can provide emotional wellbeing advantages. For example, during a work day when there is no access to highly restorative natural environments, or they can enable relaxation and stress recovery for people living in isolated confined environments. In general, the existing literature points towards the potential role of simulating nature in health and wellbeing promotion.
Going one step beyond the above mentioned studies, other researchers have integrated therapeutic narratives within virtual environments. Villani and Riva (2012) have found that a wilderness VR tropical environment combined with different relaxation exercises (based on autogenic training, progressive muscular relaxation and breathing techniques) supported by a relaxing narrative improved the users emotional wellbeing. In a similar way, Blum et al. (2019) have demonstrated that the use of a virtual beach that integrated slow breathing techniques (six cycles per minute) increased relaxation self-efficacy, reduced mind wandering, and helped the participants to focus on the present moment. Naylor et al. (2019) have also found that guided breathing exercises within nature VR scenarios can induce a positive effect on participant wellbeing.
Interestingly, other researchers have combined the exposure to nature virtual scenarios with the use of mindfulness techniques. This approach has been effective in enhancing state mindfulness and in inducing a positive affect by supporting the user’s focus of attention in the present moment within a tailored virtual setting (Seabrook et al. 2020). Finally, in a pioneering study conducted by Cebolla et al. (2019), it was found that compassion-based meditation combined with embodied VR can increase the frequency of mindfulness relaxation compared to a control group of meditation without embodied VR.
In general, it is interesting to note that all the studies that combined the exposure to virtual nature with guided meditation or breathing techniques reported significant increases in relaxation and positive mood.
We live in a multi-sensory world, where our experiences are constructed by the stimulation of five senses. One of our dominant sensory systems is the sense of smell, which is directly linked to cognitive processes such as learning and memory (Choi & Han, 2015), as well as to our emotions (Motomura & Sakurai, 2001) and mood (Warrenburg, 2005). Although most of our daily emotions and memories are activated by smells, the majority of current VR applications only rely on audiovisual stimuli. Unfortunately, the sense of smell has been largely ignored by VR developers.
Essential oils offer an accessible and viable method of providing olfactory stimulation during exposure to nature-based VR scenarios (see this post for a review of the benefits of essential oils on mental health). In particular, Cheng et al. (2020) found that combining VR and essential oils reduces stress, and increases levels of happiness and life satisfaction in older adults. Oyama et al. (2000) observed that the use of essential oils during exposure to nature-based VR scenarios (a lake, a forest or a country town) is an effective method for reducing fatigue and emesis (vomiting) in cancer patients receiving chemotherapy in an outpatient clinic. In a similar way, Hedblom et al. (2019) have also found benefits in stress reduction when combining nature-based VR environments (a park and a forest) with essential oils.
Using a novel approach, Kaimal et al. (2020) found that the inclusion of an olfactory stimulus (a calming fragrance blend) during a VR art-making session reduced the negative affect of healthy adults. FInally, Schebela et al. (2019) observed that a multi-sensorial experience composed of VR and “nature”-based scents was associated with better stress recovery than a visual-only experience. In general, current studies suggest that multi-sensorial VR experiences which include essential oils are effective at improving the psychological wellbeing of clinical and non-clinical populations.
To conclude, it is relevant to mention that the inclusion of olfactory stimuli in virtual environments increases the sense of presence (the sense of being inside the virtual scenarios) (Munyan et al., 2016; Narciso et al., 2020) and the sense of reality (Baus et al., 2019). As a result, these types of multimodal experiences will be capable of inducing more intense emotions (Alsina-Jurnet et al., 2011) such as deeper states of calm and relaxation.
At Relax VR, we combine exposure to virtual natural landscapes, therapeutic narratives (based on guided meditations), binaural beats and organic essential oils, with the aim of improving the quality of life and the emotional well-being of its users. Recent studies have shown the efficacy of Relax VR to:
These findings suggest that VR is an effective and affordable tool to reduce negative emotions and promote relaxation in the general population. It also gives new scientific evidence that supports the restorative effects of experiencing natural virtual environments.
Regarding the efficacy of specific components of Relax VR, a pioneering controlled study conducted by Krainbuhl et al. (2022) explored the effects of including a therapeutic narrative within a nature-based scenario, with the aim of enhancing the analgesic (pain-relieving) effects of VR. The results of the study demonstrated that the inclusion of a therapeutic narrative in the VR-world significantly improved pain tolerance and increased the levels of enjoyment during a painful procedure. This study represents a significant advancement in understanding the specific effects of therapeutic narratives in virtual environments.
In another pioneering controlled study based on Relax VR (Alsina-Jurnet et al., in press), the researchers compared the efficacy of VR with a traditional audio technique in patients with severe mental health disorders. Participants were assigned to either an experimental group that listened to a therapeutic narrative or an experimental group that experienced the therapeutic narrative within a nature-based virtual world. All participants completed the procedure from their own houses once per day during a two-week period. The results showed that the combination of VR and the therapeutic narrative resulted in reduced dropouts, improved program adherence, increased patient satisfaction, and reduced negative emotions to a greater extent.
In general, those studies provide evidence about the efficacy of combining two specific components of Relax VR: VR nature-scenes and the therapeutic narrative.
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