The recommendations below are strategies to minimize the potential for VR use to be experienced as triggering and to help persons with trauma histories fully engage with VR.
Rationale: Mindfulness practice in general has been linked to multiple positive outcomes. VR mindfulness has been reported to be a useful tool for engaging persons new to mindfulness and helping users establish an ongoing mindfulness practice. Persons with trauma histories and/or current trauma-related distress may report experiencing distress when using VR due to losing track of their surrounding environment as they become immersed in the virtual environment. However, VR is not contraindicated for this population. Alternatively, for persons who are interested, there are multiple strategies that can be implemented to facilitate VR as a positive and beneficial experience.
Recommendations:
*Note: The following recommendations are in no particular order and may not be applicable for all persons or across all settings. Orienting potential users to VR and talking through these strategies prior to VR use is recommended.*
❖ Allow users to become familiar with VR equipment; have them practice wearing it and help them gain mastery with how to put it on, take it off, etc. so that they are comfortable with the equipment itself prior to first use with mindfulness (or other clinical) content.
❖ Discuss option for using headphones along with VR headset ahead of time to allow for conscious and informed choice, as the pros/cons of headphones could be different based on the individual.
- Headphones could help increase engagement and reduce distress caused by outside environmental distractions by increasing sense of immersion into virtual world and minimizing awareness of outside noise. For example, a user may not be able to fully engage with virtual content if noises from the room are triggering.
- Headphones could be associated with a stronger experience of being triggered if the user feels more distressed by being fully cut off from the outside environment or if the headphones are experienced as uncomfortable or restrictive.
❖ Consider content that users will be accessing.
- Describe content (and review any images if possible) with users ahead of time. This includes presence and type of music, tone and gender of audio guidance, and description of visual content.
- Identify potential triggers. For example, birds flying in an environment that is supposed to be peaceful could be triggering to someone with a specific trauma history or fear of birds.
- Deliberately choose environment with a focus on calming stimuli, especially initially for users who are feeling anxious about VR.
❖ Provide a private room for the user if possible.
❖ Structure environment for user to be able to have their back against the wall during VR use.
❖ Orient users to the fact that they have the option of just holding the VR headset up to their face rather than using the head straps if the head straps feel too restrictive.
❖ Provide psychoeducation on benefits of mindfulness, habituation to anxiety, and how to cope with an anxiety response during VR ahead of time.
❖ Identify specific coping options to anxiety/feeling triggered during VR use that work for the site and the user:
- Use grounding tools
- Use breathing (e.g., diaphragmatic breathing, box breathing, slow/deep breaths with long exhale)
- Remind self: “I am safe” or other calming statement or mantra
❖ Provide users with access to grounding tools/objects that can be used as needed during VR sessions:
- Fidget objects (e.g., stress ball, familiar handheld objects, fidget cube, etc.)
- Soft blanket
- Warm or cold objects (e.g., warm beverage, ice, ice water)
❖ Remind users that they can take a break or disengage from VR at any point during the session.
- Ask users to try to avoid taking frequent brief breaks or pauses due to anxiety during a single VR. This can actually have the unintended impact of increasing anxiety associated with VR over time because habituation is being blocked and learning that VR is dangerous is occurring.
- In the case that a user does disengage due to anxiety, consider asking them to return to headset use after a break and using coping skills.
❖ Consider starting with shorter sessions and working toward longer sessions.
❖ Process the VR experience afterward, particularly for someone who was highly anxious about VR, reported feeling triggered, and/or took many breaks during a session.
- Users can reflect on their experience and changes in their anxiety, mood, etc. and what they are taking away from the experience.