CleVR arose from previous research collaboration between TU Delft
(Interactive Intelligence Group) and the UvA (Clinical Psychology).
In direct co-creation with researchers from various Dutch universities,
mental health institutions, child and adolescent psychiatry, forensic psychiatry
and government institutions, CleVR designs dynamic interactive virtual social worlds
for effective behavioural change for the (Mental) Healthcare and Training sector, known
as Virtual Reality Exposure Therapy (VRET) or Virtual Reality Cognitive Behavioural Therapy (VR-CBT).
CleVR operates at the crossroads of psychology and technology; that's where our focus lies. Thanks to our extensive knowledge and experience in both areas, we are able to convert various challenges within current treatment practice into solutions in Virtual Reality, with the focus on realizing more effective interventions and cost savings through a more efficient approach.
The virtual environments developed by CleVR are not only interactive; they are also dynamic. This means that the participant's behaviour determines which events will take place within a virtual world. For example, a participant's 'correct behaviour' activates different reactions within the virtual world than 'incorrect behaviour'. Within our virtual worlds, nothing is 'scripted', so nothing is fixed, every VR experience is guaranteed to be different. This is in contrast to many other VR providers and games, which makes CleVR unique.
CleVR has developed into the market leader in Evidence-Based Virtual Reality solutions for the effective treatment of mental disorders in The Netherlands. This success is due to the close cooperation between CleVR and the aforementioned branch partners.
CleVR's VR-CBT software receives the CE mark of quality as a medical device.
Based on the Medical Instruments Regulation (MDR), new rules apply to medical devices. A manufacturer may only offer a medical device on the market if it meets these legal requirements.
The VR-CBT software can therefore be safely used as a medical aid within (mental) healthcare.
The Dutch Healthcare Authority (NZa) has honoured the innovative healthcare performance application 'Virtual Reality cognitive behavioural therapy' (VR-CBT) in the context of the administrative rule 'Innovation for small-scale experiments' (BR/REG-17163). The registration number of this experiment is EI-379 under Performance Description Decision 7200-1900-18-02. The application to the NZa was submitted by the health insurer DSW together with healthcare provider GGZ Delfland, in collaboration with CleVR
Vektis has assigned VR-CBT care performance codes for both Specialist healthcare and Basic healthcare
- performance code list 050 code 270024 (Specialist healthcare)
- performance code list 063 code 40033 under 'innovation' tab (Basic healthcare)
Based on the care performance honoured by the NZa, it is possible to claim a VR surcharge via the optional performance scheme in addition to the existing (regular) reimbursements that are used for the use of CBT. This surcharge meets the start-up and on-going investments that are made for the purchase and maintenance of the hardware, software and training.
Institutions submit a quotation (incl. NZa application and decision) to health insurers with the request whether they may provide the healthcare service on the basis of the performance description decision. A health insurer indicates by means of a confirmation letter to the institution that it complies with the contents, as stated in the NZa application.
The institution can then make use of the option offered by the care performance. An institution informs the NZa by means of a follow-up agreement that it wishes to be part of the experiment agreement, as described in the NZA application.
The surcharge explicitly concerns the use of validated dynamic interactive Virtual Reality in combination with Cognitive Behavioural Therapy. The care performance honoured by the NZa does not apply to all interventions that use Virtual Reality. For example, Exposure Therapy with 360-degree videos is explicitly excluded.
Within the care performance model, this arrangement is part of the optional performance. With the optional performance it is possible to determine a performance description that deviates from the performance determined by the NZa. This means that care can be provided that would otherwise not fit into the budget. A healthcare provider and healthcare insurer must jointly submit a request for an optional performance to the NZa.
1. Psychotic disorder (experienced psychosis, anxiety and paranoid as residual complaints)
2. Social Anxiety Disorder
3. Panic disorder (with and without agoraphobia)
4. Generalized Anxiety Disorder
5. Depressive Disorder with Anxious Mood
7. Anxiety complaints in the context of a personality disorder
8. Addiction Disorder
9. (Severely behaviourially impaired) mildly mentally retarded
12. Antisocial personality disorder
13. It is possible to add the use of VR-CBT in other disorders. This takes place on request and after consultation with the health insurer
In co-creation with various institutions new functionalities and dynamic interactive virtual environments are constantly being developed. The control panel is becoming increasingly user-friendly and intuitive. The growth in virtual environments and the associated functionalities also results in the possibility of facilitating an increasingly large target group with effective VR solutions. Previously, for example, it was only possible to have one-on-one conversations with virtual characters. Now it is also possible to enter into group conversations in order to simulate social pressure in particular. The various VR applications are already being used successfully for the treatment of various disorders in a social context by means of exposure therapy.
Since 2019, the VR software includes a new Perspective Switch module that previously had not been developed in combination with VR. This unique module can be used in the treatment of personality disorders, where the application of 'changing perspective' is part of the treatment.
With the use of the perspective switching module, the practitioner/trainer can record and play back a role-playing session. The recorded conversation can be replayed from multiple perspectives. In this way, the client/participant can review the recorded conversation from the perspective of the other person (for example, from the conversation partner or when a child is present from the child's perspective). It is also possible to review the conversation from the point of view of a third (neutral) person (for example, in the case of schema therapy, a healthy adult) who was not initially present during the conversation
The innovative nature of VR-CBT is that a new, modern technology is used to improve the exposure component of CBT. The exposure can take place under the supervision of the psychologist in the safety and privacy of the consultation room, without the patient having to leave the door. The technique of the software makes it possible to offer the situation completely customized for the patient and to adjust it where necessary. The practitioner also sees what the patient sees in the exposure and can directly influence the number of virtual characters (or other environmental factors), as well as the emotions and behaviours displayed.
Thanks to the possibility to offer patients tailor-made scenarios and to offer the practitioner the possibility to check these in real-time, it is expected that the quality and effectiveness of the treatment will be positively influenced. The latter has already been demonstrated within the Randomized Controlled Trial (RCT) with the title: 'The effect of Virtual Reality Exposure Therapy on social participation in people with psychotic disorder (VRET-P).
The VR products are also used in various training courses (especially psychopathology and resilience training) for professionals within the mental health care sector, forensic sector and various government institutions. Clients are also subjected to aggression regulation training, including the RCT VRAPT (Virtual Reality Aggression Prevention Therapy).
In addition to a new software platform, which incorporates the latest technical developments in the field of dynamically interactive Virtual Reality, CleVR has developed a completely new control panel. Like the software platform, this control panel is regularly updated, including on the basis of feedback received from researchers and users. For example, the new control panel has been made suitable for mobile devices such as tablets.
The innovations contributed to the user-friendly design of the control panel. It offers researchers and practitioners the opportunity to operate the VR system in an intuitive way, so they can fully concentrate on interacting with the client and not on operating the VR system.
The practitioner has the option to record the voice of the virtual character. The voice is distorted by special software so that the client does not experience the voice of the practitioner. It is also possible to give guidance and instructions during the VR treatment, the interaction with the virtual character is then paused at that moment.
The VR systems are mobile and come in a robust rolling case. The VR system is easy to (dis)-assemble in 10 minutes. The various cables and associated connections are labelled, which makes connecting very easy. The mobile VR system can therefore be moved relatively quickly and easily.
De activities of CleVR consist of:
CleVR's products consist of custom hardware, service & support, on-site training, custom software development and software licenses.
‘Social Worlds VR-software’, this is a complete software package consisting of the following modules:
The VR systems are mobile and come in a robust rolling case. The VR system is easy to (dis)-assemble in 10 minutes. The various cables and associated connections are labelled, which makes connecting very easy. The mobile VR system can therefore be moved relatively quickly and easily. The user-friendly VR system is composed of two mobile computers (Touch laptop and Gaming laptop), VR glasses, Headset with microphone and additional parts.
If necessary, the CleVR helpdesk can be contacted during office hours. The CleVR helpdesk is ready to answer all questions and solve any technical challenges as soon as possible. Most problems are solved by telephone within a few minutes, so the practitioner can immediately continue the treatment.
If it is not possible within an institution to set up a room especially for the use of Virtual Reality, CleVR has developed a VR cart that is easy to move within the same building. The VR system no longer has to be built up; it is a matter of plugging in the power and sliding out the drawer to be able to start the VR session.
CleVR offers service contracts that are renewable annually. The service contract offers users 24 hours of service on an annual basis. This service applies to our telephone helpdesk as well as on-site service. All hardware purchased through CleVR has a standard warranty of at least one year.
CleVR offers user training as standard with every delivery of a VR-CBT system on location. This training is indispensable to be able to treat practically with a VR-CBT system from the first moment on. The duration of the training is at least one half day and lasts approximately five hours. Practitioners who have already been trained can then provide follow-up training to other practitioners internally. If desired, CleVR can play a role in further training. However, in this case there are additional costs involved.
The VR-CBT schooling in the treatment of psychotic disorders is provided by the Cognition and Psychosis Foundation
and the UMCG University Centre for Psychiatry. You can register via the website of VRmentalhealth.nl, tab 'training'.
Some experience with cognitive behavioural therapy is required to be able to follow this training.
Experts in the field of VR and CBT, in collaboration with the RINO Group, will give the master class 'Virtual Reality and CBT - How do you use VR in cognitive behavioural therapy'?
In co-creation with researchers and based on feedback from our users, CleVR is continuously developing new dynamic interactive VR applications. Using VR glasses, the user is introduced to various realistic dynamic interactive (social) worlds. It is these worlds that form the basis of the VR-CBT treatment. Together with the therapist, the client will 'discover' the conditions under which certain thoughts and behaviours are given shape and content. Dynamic interactive Virtual Reality has a strong influence on our brains and therefore strongly influences our feelings and thinking patterns. Various scientific VR studies
have shown that the use of VR glasses leads to a higher involvement ('full immersion') than simply interacting with a VR environment on a screen. (2D).
CleVR has gained a lot of experience in developing dynamic interactive custom-made software in direct co-creation with researchers and users. It is this software that forms the basis of various scientific studies and validations. The power of CleVR therefore lies in being able to make the right translation between psychology and technology. The development processes that CleVR embarks on with its partners are iterative in nature. Characteristic of this working method is that we, both our partners and we, gain new insights during the development process. For that reason, adjustments are made on an on-going basis.
Thanks to this working method, there is continuous scope to further increase quality, to respond flexibly and to leave room for 'trial & error'. New items that need to be implemented in the software can easily be included in this way. This method also ensures that the communication between the partners is completely transparent. CleVR informs its clients at fixed intervals about the progress of the development process, often using the SCRUM methodology
The software currently contains 11 different environments from which the practitioner can choose to introduce the client to and practice with them within a particular scenario. There are now virtual environments of a supermarket, shopping street, café/restaurant and office/treatment room, public transport (bus), domestic environment, detention centre (Custodial Institutions Agency), an outdoor square (school/community centre), park, presentation/conference room, counter/reception with waiting area.
Within the 'Social Worlds - Walking around' module, the practitioner has access to various dynamic interactive virtual worlds. This allows it to load a wide variety of everyday (social) scenarios as exposure. The practitioner can gradually build up or reduce the complexity of the scenarios in a controlled manner and offer the client completely tailor-made content. The virtual worlds are not only interactive in nature, but also very dynamic. Interactive because various situations react directly to the client's behaviour. Dynamic because the practitioner can introduce changes within the virtual environment at any time. As a result, each exposure session is a tailor-made session, fully focused on the real needs of both the client and the practitioner. Unlike regular games and the use of Virtual Reality with 360-degrees film material, nothing is scripted within CleVR's dynamic interactive virtual environments; it is custom work, which is also the successful ingredient for Evidence Based applications!
An example of the dynamic nature of the ‘Social Worlds - Walking Around’ module is ramping up the crowds within a virtual world by adding more virtual characters. It is also possible to adjust the male/female ratio and ethnicity within the virtual characters. Also, realistic expressions and behaviours of virtual characters can be controlled with the help of the redesigned user interface.
For example, it is possible to adjust the viewing behaviour of the bystanders towards the client, as well as the emotions with which bystanders walk around. This applies in general as well as for specific (groups of) bystanders with whom the client has certain associations.
All this gives the practitioner the opportunity to offer a customized VR-CBT session. This gives the practitioner the opportunity to gain a better understanding of the conditions under which certain thoughts and behaviour develop in the privacy and security of the treatment room. The practitioner can observe what the client sees and feels. Normally, the practitioner is not present in daily life, but now he is. Taking a better anamnesis is one of the new possibilities.
Within the regular CBT treatments, the client is often given homework assignments and the practitioner is not present during the exposure. With the help of VR-CBT, the practitioner is able to 'bring the street into the treatment room' and deal with stressful situations together with the client and make them directly discussable. The therapist maintains full control over the situation at all times.
To further facilitate the implementation of VRET-P, a special VR-CBT treatment protocol has been developed. Please contact CleVR for additional information about the training and the treatment protocol.
VR-CBT is an important addition to existing forms of cognitive behavioural therapy, in which people learn to change negative thoughts and practice with situations that cause fear, forms of aggression or paranoid thoughts in daily interaction. For example, people with psychosis are often very suspicious. They may perceive eye contact with a stranger as a threat and assume they are the subject of other people's conversations. In extreme cases, they may even think that people are plotting against them or following them. It is not easy to persuade them to take to the streets and practice for themselves.
By using dynamic interactive VR-CBT within regular CBT treatment, clients are given the opportunity to gradually get used to certain situations within different social environments.
CleVR has developed dynamic interactive Virtual Reality software that gives a whole new meaning to effectively performing role-plays within a treatment and training.
Experience shows that with VR participants can better empathize with the situation on offer, which also creates a more natural interaction. VR completely immerses the client in a specific and simulated situation.
In contrast to the current situation, the client does not have to imagine a (role-play)-situation. Thanks to the use of dynamic interactive Virtual Reality, the participant is immediately part of an offered (virtual) situation and, together with the practitioner, can concentrate on it without distraction.
The latest VR technology makes it possible to let virtual characters interact with the participant in a natural way. The client can conduct dialogues in a realistic way without being tied to a pre-programmed script. CleVR's voice-distortion techniques, in which a male practitioner can also use various female voices in addition to various male voices and vice versa, means that the participant does not recognize the practitioner's voice.
In addition, the practitioner can tailor the virtual characters within social situations, simulating a wide variety of emotions and behaviours. For example, it is possible to make the virtual character appear aggressive with the help of negative emotions, along with aggressive postures and movements. The opposite is also possible; a virtual character can also be very friendly and understanding. It is up to the practitioner to set up and present these situations.
The practitioner has the option to choose from more than 150 different virtual characters that can be used as opponents of the participant. The virtual character database consists of men, women and children of different ethnicity, clothing, stature and height. Certain characters also represent a certain function, such as a police officer, firemen, ambulance paramedics, security officer, bus driver, shop assistant, nurse, people in costume (e.g. managers), 'loiterers' etc.
CleVR is constantly active in maintaining and renewing the software, often in direct co-creation with (research) partners. By adding new functionalities and environments, our VR-CBT software is becoming increasingly accessible to a greater diversity of client groups.
Our latest functionality now makes it possible to have group conversations within a virtual world. It is possible to load multiple virtual characters into a virtual environment with which the client can interact. These group conversations can be conducted in all available virtual worlds. A job interview? A blind date? Into the pub? A meeting with dealers, with agents? A lot is possible, both in a standing and sitting position. Thanks to this software, the practitioner can gradually increase and decrease the complexity of the offered scenarios, fully geared to the real needs of both the client and the practitioner. Nothing is scripted, everything is dynamic, real-time and customised!
During certain VR role-plays, it is important that the client can experience their 'own' hands. CleVR has this capability built in. This possibility can contribute to an even more realistic sense of presence within a virtual environment, also because the virtual hands move along with their own hands. Furthermore, it can help the client to better estimate the distance to the virtual characters. Shaking hands is also an option.
The control panel is intuitive and user-friendly, so the practitioner can easily control several virtual characters at the same time and use these characters to enter into a realistic interaction with the client. The focus on the client is maintained.
'Change of Perspective’ is similar in use to the 'Role-play' module, but has extra functionalities.
Using the perspective switching module, the practitioner can record and play back a role-playing session. This means that the conversation and behaviour can be looked at again from different perspectives. Namely from the:
Imaginary rescripting can be applied within this Change of Perspective module, looking at certain interaction, memories or experiences in a different way and thus changing the meaning.
The emotion recognition exercise can be used to test how good a client is at recognizing emotions based on facial expressions. This is done by approaching various characters in a shopping street environment. When the client approaches such a character, the character shows an emotion. The client must then select the appropriate emotion from a list of possible responses.
In this module, the client faces three characters in a shopping street environment. When the practitioner starts a new exercise, the characters all show different emotions. The client must then indicate which character best fits the statement or question shown, for example with the question which character is the most angry or sad.
In the 'Catwalk' module, the client stands still on the street. A virtual character walks up to the client and says something to the client. This is a script. This means that a pre-programmed and recorded voice, posture, facial expressions and gestures are used.
The module consists of various (aggression) levels. Level 1 is a very normal and non-aggressive interaction and level 4 is a very aggressive one. The client then indicates what he/she thinks the intensity of the interaction is.
We kindly refer you to the Media section of our website for additional references. There you will find an overview of scientific papers in which research has been done with the VR treatment software developed by CleVR, in direct co-creation with researchers and practitioners. Under Media you will find, in addition to user experiences, visual material including various webinars and reports from, among others, NOSop3, RTL en Nieuwsuur.