PERSPECTIVE
published: 17 February 2021
doi: 10.3389/frvir.2021.627059
Virtually Real, But Not Quite There:
Social and Economic Barriers to
Meeting Virtual Reality’s True
Potential for Mental Health
Daniel Pimentel 1,2*, Maxwell Foxman2, Donna Z. Davis1,2 and David M. Markowitz2
1Oregon Reality Lab, School of Journalism and Communication, University of Oregon, Portland, OR, United States, 2School of
Journalism and Communication, University of Oregon, Eugene, OR, United States
Strategies to mitigate the spread of COVID-19, namely quarantine and social distancing
protocols, have exposed a troubling paradox: mandated isolation meant to preserve well-
being has inadvertently contributed to its decline. Prolonged isolation has been associated
with widespread loneliness and diminished mental health, with effects compounded by
limited face-to-face access to clinical and social support systems. While remote
communication technologies (e.g., video chat) can connect individuals with healthcare
providers and social networks, remote technologies might have limited effectiveness in
Edited by: clinical and social contexts. In this review, we articulate the promise of Virtual Reality as a
Federica Pallavicini,
University of Milano-Bicocca, Italy conduit to clinical resources and social connection. Furthermore, we outline various social
Reviewed by: and economic factors limiting the virtual reality industry’s ability to maximize its potential to
Caroline Hands, address mental health issues brought upon by the pandemic. These barriers are
University of Liverpool, delineated across five dimensions: sociocultural, content, affordability, supply chain,
United Kingdom
Nikos Papadopoulos, and equitable design. After examining potential short- and long-term solutions to these
Aristotle University of Thessaloniki, hurdles, we outline potential avenues for applied and theoretical research seeking to
Greece
validate these solutions. Through this evaluation we seek to (a) emphasize virtual reality’s
*Correspondence:
Daniel Pimentel capacity to improvemental health by connecting communities to clinical and social support
pimend@uoregon.edu systems, (b) identify socioeconomic barriers preventing users from accessing these
systems through virtual reality, and (c) discuss solutions that ensure these systems can
Specialty section: be equitably accessed via changes to existing and future virtual reality infrastructures.
This article was submitted to
Virtual Reality in Medicine,
Keywords: coronavirus, social connection, COVID-19, loneliness, mental health, virtual reality
a section of the journal
Frontiers in Virtual Reality
Received: 27 November 2020 INTRODUCTION
Accepted: 06 January 2021
Published: 17 February 2021 The COVID-19 pandemic has stressed the foundation of our institutions, from healthcare to
Citation: education (Crawford et al., 2020; Greenberg et al., 2020), and its consequences have been far-
Pimentel D, Foxman M, Davis DZ and reaching. Globally, people are faced with health-related uncertainties (Will I get sick?), job
Markowitz DM (2021) Virtually Real, insecurities (Will I lose my job?), and fear that distance from our social connections will
But Not Quite There: Social and become normative (When can I see my family safely?). A tacit concern also gaining steam
Economic Barriers to Meeting Virtual
relates to the pandemic’s immediate and downstream effects on mental health. According to the
Reality’s True Potential for
Mental Health. Center for Disease Control, in August 2020 more than 40% of United States adults reported “at least
Front. Virtual Real. 2:627059. one adverse mental or behavioral health condition” such as anxiety, depression, stress related to the
doi: 10.3389/frvir.2021.627059 pandemic, or substance use to cope with those stresses (Czeisler et al., 2020).
Frontiers in Virtual Reality | www.frontiersin.org 1 February 2021 | Volume 2 | Article 627059
Pimentel et al. COVID-19: Barriers to VR’s Potential
In such times of heightened anxiety or stress, the modus 2008). While being alone does not directly imply loneliness,
operandi for clinicians is to recommend cognitive, behavioral, actual/perceived isolation and loneliness can negatively affect
and mindfulness interventions (Marchand, 2012). However, the mental health (Holt-Lunstad et al., 2015; Loades et al., 2020;
inability to safely deliver in-person services during the pandemic, Luchetti et al., 2020).
coupled with increased patient demand and limited practitioner Clinical treatments to mitigate loneliness and associated
bandwidth (Huskamp et al., 2018; Lo et al., 2020), represent key ailments (e.g., depression) range from one-on-one mindfulness
barriers to treatment. Individuals may therefore rely upon training to group therapy (Cacioppo et al., 2015). Limited access
informal social support systems, such as friends and family, to to in-person treatments has led clinicians to pivot toward
cope with stressors, but the pandemic has largely reduced access telemental health delivery methods, such as web-based therapy
to such sources of social support (Palmer et al., 2020). The sessions (Zhou et al., 2020). Despite its accessibility and
barriers preventing clinical and social systems from meeting convenience, telemental health delivery can feel impersonal
the needs of affected communities have thus shifted attention and might interfere with the patient-clinician relationship
toward new strategies for remedying the pandemic-related (Connolly et al., 2020). Alternatively, recent work comparing
decline in psychological well-being (Moreno et al., 2020). Skype- and VR-based mental health service delivery found VR
Historically, information and communication technologies outperformed telehealth modalities in terms of perceived
(ICTs) have empowered medical institutions to meet mental effectiveness, realism, and connectedness to clinicians (Pedram
health needs with scalable solutions, from online support et al., 2020).
groups to web-based health screenings (Lal and Adair, 2014).
Virtual Reality (VR) represents a recent ICT development with
the potential to revolutionize clinical and social support because VIRTUAL REALITY’S CLINICAL POTENTIAL
of how it leverages head-mounted displays (HMDs) to swap a
user’s real-world sensory experience with that of computer Early scholarship touted the benefits of using clinical VR
generated one (Bailenson, 2018). This immersion ultimately applications to address mental health issues (Rizzo and Kim,
contributes to a subjective sense of “being there” (spatial 2005). Today, VR continues to be a valuable tool for practitioners
presence; Steuer, 1992), and a feeling of “being with” others in seeking to remedy mental health disorders by facilitating remote
a virtual environment (social presence; Bailenson et al., 2003). connections and functioning as a standalone remedy to specific
Moreover, VR enables high levels of interactivity, translating user ailments (Rizzo, 2019; Imperatori et al., 2020; Mantovani et al.,
inputs (e.g., dialogue, behavior) into virtual actions with causal 2020; Spiegel, 2020). For example, VR has been used to treat
influence (Kalyanaraman and Bailenson, 2019). Collectively, depression and anxiety (Parsons and Rizzo, 2008; Zeng et al.,
presence and interactivity help social interactions in VR evoke 2018), PTSD (Rothbaum et al., 2001; Difede et al., 2006), and
psychological/behavioral responses akin to their real-world other mental health disorders (Riva et al., 2015; Valmaggia et al.,
equivalents (e.g., Kassner et al., 2012). 2016). In instances where clinical workforce supply may not meet
Given VR’s ability to safely transport individuals to supportive patient demand, certain mental health services (e.g., counseling)
environments, clinical or otherwise, we believe there is no better may be facilitated by automated avatars, including (virtual)
time for the technology to help with everyday mental health Sigmund Freud (Osimo et al., 2015). Compared to non-
issues. And yet, VR is scarcely adopted for such purposes. This immersive platforms, interactions with agents in VR
paper articulates how VR is primed to meet the growing need for contribute to a greater sense of social presence and perceived
mental health support (Singh et al., 2020), and how industry has affective understanding (Guimarães et al., 2020). VR can also be a
yet to meet this moment head-on due to access and culture self-help solution to reduce psychological distress by engaging in
constraints. Here, we discuss the pandemic’s impact on social mindfulness practices in relaxing environments (Riva et al.,
isolation—particularly, barriers to clinical and social support—and 2020). Therefore, VR provides patients with new access points
offer recommendations to improve our capacity for mediated for mental health care.
mental health resources during this crucial time.
VIRTUAL REALITY’S SOCIAL POTENTIAL
SOCIAL ISOLATION’S IMPACT ON
CLINICAL AND SOCIAL SYSTEMS The same affordances that make VR clinically effective also
undergird long-held perceptions of the medium (and its
COVID-19’s normalizing of extended periods of social isolation is predecessors) as revolutionizing human connection and
uniquely problematic because (a) social connections are vital to socialization. Claims that VR could be “the next big thing for
maintaining physical and mental health (Eisenberger and Cole, mental health” (Martin, 2019) emerged before COVID-19
2012), and (b) over 25% of homes in developed nations are one- (Srivastava et al., 2014). Previous work shows VR can help
person households (Klinenberg, 2016). The “new normal” of individuals form meaningful social bonds with distant others
prolonged isolation has also led to a troubling increase in (Tarr et al., 2018;Wiederhold, 2018), cope with loneliness (Bahng
loneliness among adults (Killgore et al., 2020; Krendl and et al., 2020), and improve mood (Browning et al., 2020).
Perry, 2020; van Tilburg et al., 2020), or the subjective sense Moreover, VR applications designed for vulnerable populations
that one’s social connections are deficient (Cacioppo and Patrick, to engage in social activities (e.g., singing) can contribute to mental
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Pimentel et al. COVID-19: Barriers to VR’s Potential
well-being via heightened connectedness and enjoyment (Tamplin marketplaces like Steam. This narrows choices for consumers:
et al., 2020). most VR content they encounter is embedded in entertainment.
The success of VR’s predecessors, screen-based games and For instance, the most common genres of immersive-only
social virtual worlds also suggest these platforms could be content in the Steam marketplace included action and shooter
effective in alleviating social isolation and loneliness (Davis games (Foxman et al., 2020). And, for a variety of reasons
and Calitz, 2014). Since the pandemic’s start, the virtual world (including hardware), many of these experiences tend to be
Second Life, saw a resurgence in use globally (Dodd, 2020; Egan, socially isolated single-player games (de Regt et al., 2020).
2020), leaving many to claim, “the confined are ‘found’ in virtual Even when single-player games place users alongside
worlds” (Le Monde, 2020). Equal enthusiasm was expressed for automated virtual characters, these parasocial interactions are
game worlds such as Fortnite which also saw record numbers in less effective at reducing loneliness compared to co-player VR
the same timeframe (Egan, 2020). And while these platforms are experiences involving other users (Liszio et al., 2017). Thus, even
designed to create community through social interaction, if consumers associate VR with social connection, content
recreating that experience in an HMD has yet to reach broad facilitating multi-user interactions remains limited, limiting
adoption. VR’s capacity for social support.
Affordability
BARRIERS TO WIDESPREAD VIRTUAL Economic and cultural norms from the industry can narrow,
REALITY USE rather than foster, social cohesion, as well as hinder access to
communities outside of gaming. A primary issue is hardware
If the need for social interaction has spurred interest into virtual costs, which range from US$300–US$1500 , and remain out of
worlds, and the benefits of such interactions can be augmented by financial reach for most consumers. These financial hardships
VR’s unique affordances, one would expect industry-wide exacerbated by COVID-19 leave people with little to no means of
emphasis on shifting social systems onto immersive platforms. accessing meaningful virtual experiences to connect with others
Yet, there remains a gulf between VR’s potential, both as a during quarantine. This reality is born out of VR market
palliative remedy and social network, and its widespread projections predicting a somewhat paradoxical rise of
commercial use. The barriers responsible for sustaining this immersive content due to consumer demand, while headset
gap, we argue, can be categorized broadly across five sales are expected to only account for 23% of overall revenue
dimensions: sociocultural, content, affordability, supply chain, (down from roughly a third; SuperData, 2020). Similarly, while
and equitable design. the VR healthcare market is expected to boom in the next five
years—particularly for health technology startups—there is
Sociocultural widespread acknowledgment that the healthcare system is slow
Twomajor antecedents for VR adoption include “sociability” and to change (e.g., Petrara, 2020). Researchers may tout VR’s benefits
“social warmth” (Jang and Park, 2019). From a consumer to individual therapy and healthcare (Wiederhold and Riva,
perspective, this implies VR adoption may be contingent on 2019), but public adoption by healthcare workers can only
social content: the metaverse imagined in science fiction where come after significant infrastructure changes occur (e.g.,
users virtually connect with each other. Although social VR internet connectivity, stronger case studies for cost savings;
platforms have emerged such as AltSpace VR and Sansar, Marbury, 2020). Paired with trends suggesting continued
adoption remains relatively low (SteamCharts, 2020). increases in mental health expenditure (Olfson et al., 2019), it
Additionally, HMDs have long been tied to primarily solo is unreasonable to expect that consumers will invest in a platform
gaming experiences, such as Nintendo’s “Virtual Boy.” The when its content is not ready to meet their socioemotional
ties go deeper in the contemporary moment (Foxman, 2018; connection needs.
Foxman, 2019), with tools for VR production inculcating early
adopters into gaming environments to successfully design and Supply Chain
develop content. In other words, it is not simply that the gamer Consumers who can afford headsets face an additional barrier:
identity is baked in at the consumer level, but also the producer disruptions to global supply chains. Due to quarantine
level. Associations between gaming and VR create consumer measures, hardware manufacturing and distribution
expectations of play over people, undercutting the medium’s experienced significant delays, making VR “hard to find, at
perception as a socialization tool. These parallels also risk the worst time” (Kuchera, 2020). The pandemic exposed supply
delegitimizing VR as a mental health tool in the eyes of chain fragility and the need to engage in more localized, agile
healthcare providers, as supported by the lack of insurance production processes capable of meeting market needs (Nandi
coverage for video game-based mental health interventions et al., 2021).
(Baranowski et al., 2016). Beyond needing to revamp hardware production and
distribution, consumers also face exclusionary practices on two
Content fronts. First, the existing audience for VR is built around the
Content creation and distribution on popular headsets requires stereotypical white male gamer prototype identified in the design,
working within the game industry, either through use of game marketing and even leadership of VR companies (Golding, 2019;
engines such as Unity or Unreal, or distribution via digital Harley, 2020). Second, VR’s virtual supply chain is built on game
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Pimentel et al. COVID-19: Barriers to VR’s Potential
development studios who produce content for consumer-facing scholars alike should integrate the unique expertize of medical
virtual marketplaces. Despite efforts to democratize development professionals to co-create infrastructure capable of safely and
via free platforms like Unity, the pipeline to virtual distribution effectively rendering services (Ospina-Pinillos et al., 2018). Co-
remains bound to “the monopolizing tendencies of platformization” creation should also include those who will inevitably reap the
(Chia et al., 2020), and thus would benefit from a continued push psychological benefits of VR. Incorporating patient input during
toward open-source solutions. Doing so would ensure that a wider content development ensures that virtual experiences fit their
array of simulations, including those focused on cultivating social needs. This is particularly true of older adults who face unique
connection to mitigate loneliness, could be accessed by those who obstacles as it relates to accessing and benefitting from digital
need them. mental health interventions (Seifert et al., 2019). For this reason,
in the short term, we caution against an overreliance on
Equitable Design technology-based solutions for facilitating medical or social
The VR industry’s exclusionary orientation has also resulted in interactions because these may not be inclusive of older adults
disparities that extend beyond the point of purchase. Most VR with limited comfort or access to these options.
users need a certain level of “game capital” (Consalvo, 2009), The VR industry and its content creators must also address
acquiring common game norms, skills, knowledge, and hardware accessibility issues at a socioeconomic and technical level; there is
to successfully use the headsets. For instance, controllers are an evident need to reduce barriers to entry for low-income and
challenging to novices, containing buttons familiar to gamers low-access populations. One approach may be for VR titles to
and/or designed around specific games (e.g., first-person adopt “freemium” business models, providing users free access to
shooters). Recent efforts to introduce more natural, intuitive core features of an app with the option to pay for premium
user inputs have also been problematic. For example, while services (Hamari et al., 2017). Another solution is for researchers
Oculus’ “Controller-Free” mode leverages hand gestures and designers to pair accessible hardware design with inclusive
instead of button inputs, users with medical conditions (e.g., software features (see Steed et al., 2020). Immersive content is
tremor, amputees) are limited in their ability to access spaces that seldom capable of accommodating users with visual or physical
may bring them a reprieve. Additionally, if users can access VR impairments, as experiences often require visual cues and use of
and its few social spaces, it is common to find them heavily hand controllers. This has created inconsistent accessibility
embedded with gaming imagery, trolls, and toxic behavior that standards across HMDs (Cook et al., 2019), though it may be
works against seeking connection under quarantine. For VR to remedied by providing alternative input methods. For example,
fulfill its potential for well-being, engaging in inclusive hardware/ brain-computer interfaces have shown promise as alternatives to
software design will ensure those most vulnerable to the traditional user inputs (Lotte et al., 2012), along with refreshable
detrimental effects of loneliness, namely older adults (Hawkley braille displays (Tran et al., 2019), and standardizing modification
and Capitanio, 2015) and those with disabilities (Olsen, 2018; features to account for visual, hearing, and motor impairments
Davis and Stanovsek, 2020), can benefits from the platform. (Playstation, 2020). Indeed, scholars note that minor
Finally, optimizing content for equitable use also requires modifications to VR scenes (e.g., modulating luminance) can
developers to account for fatigue: as extended use can cause make VR experiences accessible to users with visual impairments
physical discomfort when exceeding 30 min, VR-based (Powell et al., 2020). VR content creators must follow suit by
interventions should be optimized for such intervals and placing accessibility first and ensuring the mental health benefits
incorporate breaks (Thai et al., 2020). of VR experiences are available to all users, regardless of sensory
and mobility limitations.
According to mood management theory, media consumption
DISCUSSION is heavily motivated by hedonic concerns of either maximizing
pleasure or minimizing pain (Zillmann, 1988; Oliver, 2003).
Taken together, we call upon academics, industry leaders, and Given VR’s capacity to effectively induce specific moods, and
clinicians to take the relationship between social isolation and VR since such emotional responses can be more pronounced in VR
seriously. Evidence suggests VR is a promising tool capable of compared to 2D content (Diniz Bernardo et al., 2020), VR as a
connecting humans to clinical and social support systems that mood manager is a viable designation. However, for this potential
may reduce the adverse effects of the pandemic. Yet, given the to be realized at scale, content should enable customization
barriers identified herein, ensuring an equitable and effective interfaces to empower users to manipulate their virtual
implementation of VR-based solutions, clinical or otherwise, environments and meet their emotional needs. Mood
remains unclear. Thus, we propose the following recommendations induction experiences should not exist as standalone apps that
for clinicians and industry leaders to improve the lives and mental may otherwise clutter the virtual marketplace, and rather should
health of global communities. be integrated into existing infrastructure, such as social VR
Equitable distribution of innovative healthcare technology is applications.
predicated on co-creation: inclusion of all stakeholders at all When users are not actively seeking to manage their emotional
stages of a product’s development (Nambisan and Nambisan, states, emerging VR functionalities may help nudge users toward
2017). VR is inherently an interdisciplinary platform, informed more optimal moods. Affective computing studies illustrate the
by the fields of psychology, computer science, game studies, capacity of mobile devices to discern human emotional states
architecture, and among others. As such, developers and from various user data sources (Picard, 2016). Specific to VR,
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Pimentel et al. COVID-19: Barriers to VR’s Potential
non-verbal data (e.g., posture) provide unprecedented opportunities establishing its place among the growing suite of “positive
to tailor content to users (Miller et al., 2020). It will be possible to technologies” (Riva et al., 2020).
actively model how people think and feel during a crisis and adjust
virtual environments or content suggestions accordingly, much like
the burgeoning mobile meditation app industry. DATA AVAILABILITY STATEMENT
While a single technology may not remedy the psychological
strain of COVID-19 and social isolation, VR’s potential as a The original contributions presented in the study are included in
conduit to clinical and social support systems cannot be the article/Supplementary Material, further inquiries can be
overstated. The recommendations highlighted herein prompt directed to the corresponding author.
medical professionals, business leaders, developers, and
scholars to consider important barriers impeding on successful
development and deployment of VR content that contributes to AUTHOR CONTRIBUTIONS
the psychological well-being of users. It is our hope that this
overview guides theoretical and applied research into VR’s Authorship order reflects individual contributions to the
capacity for psychological well-being during crisis, further manuscript: DP, MF, DD, and DM.
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Tamplin, J., Loveridge, B., Clarke, K., Li, Y., and Berlowitz, D. J. (2020).
Development and feasibility testing of an online virtual reality platform for Copyright © 2021 Pimentel, Foxman, Davis and Markowitz. This is an open-access
delivering therapeutic group singing interventions for people living with spinal article distributed under the terms of the Creative Commons Attribution License (CC
cord injury. J. Telemed. Telecare 26 (6), 365–375. doi:10.1177/1357633X19828463 BY). The use, distribution or reproduction in other forums is permitted, provided the
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Thai, K. T. P., Jung, S., and Lindeman, R. W. (2020). “On the use of “active breaks” No use, distribution or reproduction is permitted which does not comply with
to perform eye exercises for more comfortable VR experiences,” in 2020 IEEE these terms.
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