You don’t do the virtual reality game Deep for fun. It was created as a fear intervention. Whether you have a fear of flying, presenting, crowds or spiders, the fear usually expresses itself in the same way. You start to worry, you avoid confrontational situations and there is a physical reaction: a general feeling of tension, increased heart rate, breathing fast and high in the chest and sometimes abdominal pain or sweating.
Deep abdominal breathing helps to calm the body. Deep is about breathing. You play it with VR glasses and a flexible belly band. You only move forward in the game if your belly goes up and down. A larger and smaller ring in the middle of your field of view shows whether you are doing it right. Seaweeds and other parts of the underwater world also react to the abdominal movement.
“Fear is a normal response to threats in the environment. But if it lasts too long, it can develop into an anxiety disorder that is limiting,” says Joanneke Weerdmeester. At the end of last year, Weerdmeester obtained his doctorate at Radboud University on game-based biofeedback interventions in anxiety disorders. She contributed to the development of Deep, and researched its effects on young people.
Anxiety disorders are usually treated with cognitive behavioral therapy, sometimes combined with medications. “It focuses, as the name suggests, very much on cognition. On your thoughts about something and the behavior you exhibit,” says Weerdmeester. “That is also very important, but it is quite difficult for children and young people. You have to be able to think about your own thoughts on a meta-level, that’s abstract. While children are often very good at pointing out what is happening in their bodies. They just don’t always link the fact that they have stomach pains or feel tense with their fear.”
Biofeedback arose in the 1970s, when the realization grew that the body, emotions and behavior are connected, Weerdmeester explains. Biofeedback gives you control over your body and the rest improves in its wake, the idea is. “The deeper and the calmer you breathe, the better, science pretty much agrees on that. But it’s hard to master. If you practice on your own, you have less idea whether you’re doing it right or not, you can’t adjust as well.”
A positive beep
That’s why feedback is important. “In the early days it looked simple. A heart rate sensor was attached to your body, and you would hear a positive beep if things went well, and a negative beep if things went less, “says Weerdmeester. “Later, it was made more fun by, for example, letting people watch a television that showed sharp images when things went well, and got noise when things went less well.” Measuring has become much easier in recent decades. Most smartphones and smart watches have heart rate monitors. VR has also become much more accessible in recent years.
Virtual reality is not just a tool to make therapy fun so that people last longer. “In VR you can simulate an environment in which the feelings and the accompanying physical reaction are actually evoked. We know that that works better than if someone just thinks back to the moment when they felt fear,” says Weerdmeester. Virtual worlds are therefore also used as exposuretherapy, in which people are confronted with their fear. Then someone has to walk into a virtual airplane, for example. “Such therapy works, and it’s easier to perform than actually walking into an airplane with someone. But often those worlds look very fake. My professor calls it “chocolate covered broccoli.” You immediately see that it is meant to teach you something, which makes it difficult to experience real emotions with it.”
Deep didn’t have to be a chocolate covered broccoli, but a real gaming experience with scientific support to be able to use it as a serious therapy. “Design and science come together here,” says Niki Smit, developer of Deep and designer at Monobanda, where Deep started. “Many therapies that deal with game elements revolve around scoring points. But that’s not what makes playing fun. Learning a ruleset, getting better at something, that’s why people love to play. That gives confidence. Deep doesn’t punish you if you do it wrong, you’re just less effective. This way you can master abdominal breathing relatively easily while playing.”
A rough version of Deep existed before Weerdmeester got involved in the development. A festival programmer who saw the first version at a festival linked the makers to Weerdmeester’s promoter. “They were already working on things that we know from science,” says Weerdmeester. “Much still had to be finely ground. For example, the feedback could be visualized much better.”
A scary shark
Once engaged, they wondered if they could bring in some form of confrontation therapy as well. Smit: “We thought we could make a scary shark or a threatening whale instead of a spider that someone is afraid of. But someone who is afraid of spiders doesn’t get the same feelings when they see a shark.” Weerdmeester: „We also kept thinking, who are we doing this for? Not just for people with a fear of spiders. We wanted to make something general, teach that breathing.” They arrived at the general feeling of tenseness that people with anxiety have. Smit: „The worst thing you can do in a game is lose control. Joanne also saw something in that, if you take away someone’s control, it can generate fear.”
What does that look like? Smit: „Lack of control, uncertainty about what is happening, then you end up in the dark as a game designer. You’re in a tunnel and you don’t know what’s around the corner. Music can support the effect.” They decided to link the light to the breath, the second level of Deep is only lit when exhaled.
The underwater world is beautiful. Two experiments had to show whether it also had an effect. First, Weerdmeester divided 112 anxious young adults (17-25 years) into two groups. Half practiced breathing in Deep, the other half had to do it with a smart-phone app with breathing exercises without feedback.
Breathing exercises help, in both groups the feelings of anxiety were reduced, up to three months after the therapy. But Deep didn’t outperform the bare breathing exercises significantly. However, Deep players reported more than app players that they felt more in control, they had more faith in their abilities to do something about the fear. “That is also a great result. Because we know from other research that these variables have a reinforcing effect on the ultimate effect of a treatment,” says Weerdmeester.
The dark level did not induce the expected heightened sense of tension. “That may indicate that the level is not yet intense enough, or that the participants had already mastered breathing to such an extent that it had less effect on them,” concludes Weerdmeester in the thesis.
Quieter in the classroom
Another, smaller, experiment with eight children (aged 12 to 17) at a special education school showed that Deep players felt less anxious after 15 minutes of play and that they were calmer in class for up to two hours afterward. “The latter indicates that this approach can also influence other domains of emotion and behaviour,” says Weerdmeester.
Weerdmeester received his doctorate at the end of 2021, but the research is far from finished. “We now want to make the translation to the real world,” says Weerdmeester. “For use in a clinical setting, we need to see how many VR sessions are useful. And also how you can combine it with other forms of therapy, and how to make it technically accessible to therapists.”
Smit also sees many other opportunities for his game. “In America, research is now being done to see whether it can help young people with post-traumatic stress, in Twente we are looking at a clinic for forensic youth care whether it can help with aggression regulation. We are also in talks to investigate whether it can help with lung covid. That may sound crazy because it’s very different from anxiety or stress, but some lung covid patients have a lot of trouble breathing and have lost confidence in their bodies.” Who knows, Deep could be released as a general meditation game, he dreams aloud. “Being able to breathe properly is actually good for everything.”