The empty cradle: how can virtual reality heal?
by Caroline, Charlotte & Clément
Providing Psychological and emotional support after perinatal Loss : Protocol for a virtual reality-based Intervention, Corno (2020)
- Introduction
Death will always remain for everyone the great question of life. But if there is one place where it becomes particularly disturbing, or even unthinkable, it is the maternity ward or a neonatal intensive care unit. It leaves all those who encounter it in deep disarray or great turbulence. Perinatal bereavement is when parents lose their baby between 22 weeks of amenorrhoea and the 7th day after birth (World Health Organization, 2021). This violent event, which takes on the value of trauma, overwhelms the psychological apparatus. The elaboration of this loss will be all the more difficult as it occurs in the context of the identity reorganisation specific to pregnancy. It is a common bereavement. It affects 8,000 families per year. According to figures from INSEE, the French National Institute for Statistics and Economic Studies, the infant mortality rate in 2020 is 3.6 (per 1,000 live births). Miscarriages are also very common, accounting for around 15% of all pregnancies and affecting one in ten women during their lifetime. About 23 million per year worldwide occur, which corresponds to 44 miscarriages per minute.
This recent article from Corno (2020) focuses on the loss of a child during the perinatal period and more specifically how, with the help of virtual reality, to alleviate the symptoms of grief, postnatal depression and other psychopathologies that result. A sample of 40 women who have experienced this trauma will test virtual reality in comparison to traditional treatment. This technique is much promoted nowadays because of its effectiveness in psychological disorders, particularly for post-traumatic stress disorders which may be associated with the loss of a child (Lognoul et al., 2020). Giulia Corno is a psychologist working at the Cyberpsychology Laboratory of the Université du Québec en Outaouais (UQO). She specializes in the use of new technologies in the field of clinical, health and positive psychology. She has participated in numerous scientific researches in the perinatal field and around body image, integrating virtual reality as therapeutic care (Corno et al., 2018).
2. The Summary of the work we are reviewing
The psychological consequences of the loss of a child are numerous, such as grief, postnatal depression and other psychopathologies. In a study conducted in 1997 by Hunfeld et al. 38% of women 4 years after perinatal bereavement showed distress and 25% had massive anxiety at the memory of their deceased child. The prevalence of complications is estimated at 25% one month after the loss of the child in utero, compared to only 1.9% to 6.9% in a conventional birth (Gouy-Masure, 2012).
The most frequent symptoms are intrusive memories (65%), reduced projection into the future (61%) and a general loss of interest in activities (57%). At four months after the loss of the child, sleep disturbances (23%) and irritability (25%) appear. The severity of the symptoms of revivification seems to be greater the later the perinatal death occurs in the pregnancy. Finally, after another pregnancy, 21% of women meet the clinical criteria for post-traumatic stress disorder (PTSD) and over the course of their entire lives, 29% of women who have experienced a perinatal death have PTSD at some point (Huche Texier-Lory & Bourdet-Loubère, 2019)
- How can we support and reduce these symptoms?
Virtual reality exposure therapy for post-traumatic stress disorder has been studied and shows very good results in terms of effectiveness.
The aim of the proposed study is to assess a Virtual-reality-based intervention for mothers after pregnancy loss in a randomized controlled trial. How can virtual reality be used as a tool to improve the quality of life? Virtual reality would be used as a tool where traumatic events are replicated in safe conditions. The virtual environment proposed in this method is “Emma World”. In this environment, symbols, landscapes and elements personalised to the patient are used to evoke the trauma of child loss that she has experienced. Thus, the psychologist can use these symbols to deal with the young mother’s negative emotions. The aim is to reach the stage of acceptance of the loss through this therapy. This method is expected to be more effective than a conventional treatment given to a patient who has experienced the loss of a child. Indeed, patients can choose between 5 different landscapes that best represent their feelings about the bereavement of their child. In the centre of each landscape is a temple with a book of life in which they can write. In this way, the patient and her therapist can follow the progress of the therapy and the progress the young mother is making in coming to terms with the loss of their child.
Two hypotheses are formulated in the article. Firstly, if the virtual reality experience is performed before the classic treatment (TAU), it will show a reduction in symptoms of grief, postnatal depression and other psychopathologies. On the other hand, if the virtual reality experience is performed after the administration of the classic treatment (TAU), there will be a pre-post effect on the improvement of symptoms of grief, postnatal depression and other psychopathologies. The target sample is composed of 40 women for which their free and informed consent has been obtained in advance (code of ethics for psychologists, 2021). The proposed rhythm of the virtual reality sessions was 2 hours each, 3 times a week.
In order to measure the results on the different psychological states of the mother, different scales are used :
- First of all, to measure perinatal grief, the Perinatal Grief Scale is used (Potvin et al., 1989). This scale evaluates coping difficulties and despair. Complications of grief are measured by the Complicated Grief Inventory (Zech, 2006).
- Depressed mood is measured by the Beck Depression Inventory (Beck et al., 1996).
- Postnatal depression is measured by the Edinburgh Postnatal depression scale (Cox et al., 1987).
- Anxiety is measured by the State and trait anxiety inventory (Gauthier and Bouchard, 1993).
- Finally, affect is assessed by the positive and negative affect scale (Gaudreau et al., 2006).
The aim was to measure these scales before and after virtual reality therapy in comparison with conventional treatment in order to validate or invalidate these two hypotheses. This study remains at the proposal stage and does not put forward any results for the moment.
3. Critical evaluation
The aim of this therapeutic intervention is to enable parents to live through the trauma of the loss of their child as painlessly as possible. It also aims to prevent the occurrence of psychopathological complications.
It is important in this treatment to think of the continuity of the multidisciplinary team which will provide a necessary restraining function and create a reference framework on which the couple will rely to recover their internal resources and their capacity to think.
As mentioned, perinatal bereavement can be experienced as a post-traumatic stress disorder.Recent scientific literature shows that the treatment of post-traumatic stress disorder (PTSD) is frequently based on exposure to the traumatic memory. The most commonly used modalities are in vivo and imaginal exposure (Lognoul et al., 2020).
Virtual reality therapy for perinatal bereavement has many advantages. They represent a choice alternative for patients who are not very sensitive to imaginary exposures and
they are an alternative for certain patients who are too fearful and/or reluctant to be exposed in vivo.
However, the main criticism of this article is that no results were presented. No figures have been provided and the reader cannot know whether the device used by EMMA World in this research was successful.
Secondly, on page 2, although the authors explain that “VR embodied the unique opportunity to create (and recreate) simulated environments where the testing, training, teaching, and treatment of cognitive, emotional, and sensorimotor processes can take place under stimulus conditions that are not easily deliverable and controllable in the physical world”, we believe that it would have been appropriate to explain, with specific and richer arguments, how virtual reality (VR) interventions can facilitate the management of emotions following a traumatic event. While it is a matter of providing psychological support, the role of the psychologist could also have been further developed. How can the psychologist support the patient during the virtual reality intervention, for example? Does the psychologist’s speech have a central place during the exercise, or should he or she remain relatively in the background to allow the patient to explore the virtual environment? Should the psychologist be trained in this practice? Does it concern psychologists working in hospitals or can it be used for patients who are not hospitalized?
Furthermore, as the authors indicate on page 6, the virtual reality intervention is aimed solely at mothers, without taking into account the feelings of fathers (or second parents). This fact is all the more striking since today, the place of fathers in the family unit and in society is becoming increasingly important. In fact, the feelings of fathers, who were going through the same mourning process as mothers and were experiencing profound upheavals after the death of their child, were greatly underestimated. If it seems essential to support the two parental figures, it is just as judicious to take care of the union of the parental couple in order to help them get through this trauma. However, if the caregivers focus their attention on the mother, sometimes neglecting the other parent, is there not a risk of creating a gap between the two parents? In this case, could an excessive gap lead to the dissolution of the marital couple? On our scale and as future developmental psychologists, it seems essential to us to consider all the people impacted by such a painful event. Moreover, it goes without saying that the father (or second parent, “a female spouse”, as indicated on page 6) can represent an essential support in the accompaniment of the mother’s perinatal mourning, and vice versa. We believe that the psychologist can provide crucial support to both parents by instilling the idea that each must respect the other’s temporality in his or her grieving process, and by helping to accept that the needs of one may be different from those of the other.
Then, on page 3, the authors state that the intervention program will be offered to mothers who have “recently” experienced a perinatal death, that is, within one year prior to enrollment. So, is this the authors’ choice or are virtual reality interventions only effective in the acute phase? Can they be effective in subjects who have experienced the loss of a child several years earlier?
Finally, in the paragraph on inclusion/exclusion criteria, after specifying that the women who benefited from the intervention program were those who had suffered a perinatal death in the year preceding enrolment, the authors mention the fact of being under psychological treatment as an exclusion criterion. We were concerned about this point because the probability of being under psychological treatment shortly after the death of one’s child seemed greater than when the trauma has occurred over a longer period of time. In our opinion, this inevitably excluded a certain number of women from the intervention program, even though virtual reality might have had significant effects on some of them. We would have liked to have had further explanations regarding this exclusion criterion.
4. Conclusion
We found this article very interesting and wanted to investigate further the literature on the subject of therapeutic interests related to virtual reality. We were not aware of this type of intervention in the context of psychological and emotional support after a perinatal loss, even though we were aware of its interest in certain adolescents with post-traumatic stress disorder, for example. It is a reading that led us to question our future professional practice and to project ourselves into the range of possible support to offer for future patients.
The use of virtual reality as a therapeutic tool remains relatively “mysterious” for us; we wonder about the effective implementation of this type of intervention. If we wish to orient ourselves towards a professional activity in private practice, for example, this raises the financial question of the installation of such a device. If, on the other hand, we wish to invest ourselves in a structure, within a multi-professional team, we question the possibility of being able to work as a team through this virtual reality device. Perhaps it would be wise to involve several professions in order to allow for a multiplicity of responses to be given to victims ?
Finally, this article questions our relationship to death, to parenthood, and the way in which we wish to mobilize our professional resources in order to best accompany people suffering from perinatal mourning. As novice psychologists and as students at the end of their training, this is a subject on which we feel we need to enrich our knowledge in order to improve our know-how and skills.
Words we have learnt
- Seldom : rare
- Transient impairment : gêne temporaire
- A toll : payer le prix
- Despair : désespoir (p.3)
- the psychic apparatus : l’appareil psychique
- embodied : incarné (p.2)
- Bereavement disorder : Trouble du deuil (p.2)
- Ilness severity : sévérité de la maladie (p.4)
Key terms
- Grief
- Miscarriage
- Bereavement disorder : Trouble du deuil (p.2)
- Stillbirth : mort à la naissance (p.4)
- reality virtual
To go further…
If you enjoyed this reading report, we suggest you read more about the experiences of these families affected by perinatal bereavement:
– The French short film “Et je choisi de vivre” by Damien Boyer : https://youtu.be/74H8NZ-WxSM
– The AGAPA association, which offers live shows on the subject of perinatal bereavement: https://association-agapa.fr/notre-actualite/
– Research on therapies proposing virtual reality, particularly in the field of post-traumatic stress disorder: “Virtual reality exposure therapy for post-traumatic stress disorders, obsessive-compulsive disorders and anxiety disorders: Indications, added value and limitations” (Lognoul et al., 2019); “La réalité virtuelle: un outil de réalisme” (Lallart et al., 2014)
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