Sasha hesitates by the door of the toilets. She’s pushed it half open and can see that one cubicle is taken, and that there is a girl standing, washing her hands at a small sink. Light from the window highlights the patches of floor where the vinyl has worn through to concrete, and there is a line of mould along the top of the tiles, which cover the wall above the sinks.

Sasha feels the familiar urge to run. Her hands are sweaty. She can hear her blood throbbing through her temples. Her breath catches in her throat.

She has a germ phobia. It’s severe enough that she has to see a therapist. That therapist has said that, today, she needs to enter the toilets and wash her hands at the sink.

So, Sasha fights back against the familiar fear and anxiety. She wants to beat this. She’s about to take a step, but just as she lifts her foot, the school bell rings, the corridors flood with pupils, the girl in the cubicle flushes the toilet, the girl at the sink starts applying make-up, there is a teacher shouting for pupils to get to class, and Sasha just crumbles.

It’s too much.

Sasha rips off the virtual-reality (VR) headset, and she’s back in her therapist’s office. She is undertaking exposure therapy - with a twist.

Most exposure therapy involves people slowly increasing their interactions with the source of their phobia - for example, for those afraid of flying, it might involve visiting an airport, then sitting in the departure lounge, moving on to board a plane and then sitting on that plane, with each transition carefully planned across an extended period of time.

It’s time consuming, difficult to control, the therapist cannot always be there without great expense to the person undergoing the therapy, and the idea itself can be enough to scare people off.

But what if the person never had to leave the therapist’s office? VR is making that possible. It’s what Sasha is experiencing in the example above, and it may have a huge impact on school attendance for some of our most vulnerable young people.

We’ve learned not to trust virtual reality. We’ve been told it’s going to change our life so often, and yet we’ve been let down every time: the experience has not been as realistic as sold, the applications have been too few to justify the price, the technology has not become as omniscient as we were promised.

But in the field of psychology, there is fresh excitement about VR, and about its use in exposure therapy, in particular. Gráinne Kirwan, a lecturer in applied psychology and cyberpsychology at the Institute of Art, Design and Technology, in Dún Laoghaire, Ireland, is a contributing author to the book Annual Review of Cybertherapy and Telemedicine. She believes that VR can remove the normal barriers that therapists encounter when using exposure therapy.

VR allows for the individual to be exposed to these settings or environments under the guidance of a therapist, without having the spider there or without actually having to go to the bridge,” she explains.

That’s better than physically having to do it for several reasons, according to VR advocates. You can put the spider in the realistic setting of the person’s home or get the individual to sit on a plane, without the logistical hassle of actually making either of those things possible. You can control the circumstances of the experience to match the precise phobia - for example, simulating a plane landing. You can do exposure therapy in a safer way: the therapist is there, every time, with the person, and the “threat” is never real.

All that control, according to Stéphane Bouchard, co-director of the cyberpsychology lab in the department of psychoeducation at the University of Quebec, could arguably make for more effective therapy.

Bouchard has conducted a randomised controlled trial comparing the effectiveness of in-person therapy to VR therapy, with children, adolescents and adults. And in every group, VR therapy was as effective as standard therapy.

“We believe that VR therapy can be even more effective,” Bouchard says. “When we do exposure for fear of heights, we can take them to a high place but they’ll still have a fear of jumping out. With VR, we can offer them the option of actually jumping out.”

But what about a student with a fear of school toilets or crowds of other pupils or other anxieties connected with school? In extreme cases, these fears are a huge part of school refusal.

Currently, there is no data collected on the number of children who are classed as school refusers. We do know that Not Fine in School, a support group for parents and carers of children who struggle to attend school, has more than 6,000 members, and that, according to Department for Education data for 2017-18, persistent absentees accounted for more than half (54.1 per cent) of all unauthorised absence.

The first stage of support for these families would involve an education welfare officer (EWO). However, in a survey conducted by Not Fine in School, just 5.4 per cent of parents said they found the EWO to be an effective source of support.

Some pupils do end up working with therapists and it is here that VR could play a role, according to its advocates, in making exposure therapy not just more effective - as outlined above - but more palatable to the young person, too.

Bouchard says the VR therapy could help these children to overcome their fears without feeling foolish - no one has to see them running away from the school toilets or becoming emotional in the playground.

“In VR, the [service users] are still in control,” he explains. “Children and adolescents, and even adults, are all afraid of looking foolish. And there is a limit of foolish things you can do in a social context that are socially acceptable. In VR, you can embarrass yourself - it doesn’t matter.”

VR is not just being used in the reactive world of exposure therapy, though: it’s also being employed to spot potential mental health concerns and could help to prevent young people from getting to the point at which exposure therapy is necessary.

The Virtual Reality Lab is led by Lucia Valmaggia at King’s College London, and is a world-leading multidisciplinary group dedicated to VR-based research, assessment and treatments for mental health. Working with Valmaggia, Charlotte Gayer-Anderson has been looking at using VR to identify students who may need a mental health intervention.

Her work was part of the REACH study, taking place in 12 secondary schools in South London, which more than 4,000 young people (Years 7 to 9) have taken part in since the project began in 2016. She wrote up her findings in her paper Risk and Protective Factors for Unfounded Paranoid Ideation in Adolescents: a virtual reality study.

“Paranoid ideation” sounds scary, but what we’re talking about here is a tendency to misread a situation. It’s the student who thinks everyone is staring at them, so avoids the library; the student who finds insult in an ordinary remark; the student who sees sniggering and derision when there is just laughter at something completely different. These are pupils who can eventually become school refusers.

Gayer-Anderson designed a VR experience in which students have to navigate a dining hall. They have three encounters: one with a boy who places a bag on a chair because he’s saving it for someone; another in which there is a group of people talking, and they stop and look around, and then carry on talking; and a third, in which a child says “hey” and waves. The avatars are programmed to behave ambiguously, and to respond to all participants in the same way.

Once they’ve been through the “dinner hall”, the students are then interviewed about their experience, and their answers analysed.

“The time in the VR simulation takes about three to four minutes,” explains Gayer-Anderson.

For the majority of the students, the encounters were seen for what they were: benign, everyday and innocuous. But for some students, the encounters were interpreted very differently.

“When asked about how they perceived those encounters, some students will perceive some of the avatars as being particularly hostile, and express feeling as if they have negative intentions towards them,” she says.

These VR experiences can build towards a diagnosis of paranoid ideation, and it is a much more reliable method of identification than some standard methodologies, says Gayer-Anderson. “We’re able to have a measure of fairness, because if we did this in a real dinner hall with actors, you can’t control the behaviour like you can with avatars because even minute nuances make a difference,” she explains.

The other way to do this is by questionnaire, and the worry with that is that when adolescents answer those questions, they might say they’re being targeted because it’s true - they are. Therefore it’s hard to tease apart what are real instances of hostility. You would have to do a real in-depth interview, which would take hours.”

The idea with the advanced-warning VR is that interventions can be put in place before the problem reaches a level of school refusal or more serious mental health concerns.

“It’s foreseeable that, in the future, VR [will] be used as a tool to identify kids who are overly anxious or paranoid in social situations, and then we can target those individuals and put help in place,” says Gayer-Anderson.

It’s a compelling idea: VR helping to spot more young people before they become school refusers, and helping those who do get to that point to conquer their anxiety. No one is claiming it will do this on its own - “VR isn’t a pill or a cure; it is always used in conjunction with CBT [cognitive behavioural therapy]”, says Bouchard - but advocates argue that it could vastly improve the outcomes we are currently getting in schools.

Clearly, it is still early days for the technology and it’s not going to be an option for every child yet, but the signs are that it may be soon. Recent investment of £10 million of funding into Oxford VR, a new VR research and treatment centre at the University of Oxford, is certainly a vote of confidence. This centre has already been working with NHS patients and will now expand.

Founder of Oxford VR and consultant clinical psychologist Daniel Freeman says he believes the technology will be embraced by schoolchildren.

“My experience is that adolescents with anxiety concerns really like the idea of VR to treat mental health difficulties,” he says. “They grasp the technology extremely quickly, they are keener than many adults to have complex interactions within VR, and they readily suggest ways it could be used to make them less anxious.”

Wider use, though, will depend on more research, according to Jeremy Bailenson, of Stanford University, who co-authored Virtual Reality 101: what you need to know about kids and VR.

In his research Considering Virtual Reality in Children’s Lives, he found that in the minds of younger children, virtual worlds merge with the real world. The memory of watching their avatar swimming with dolphins becomes their memory of them doing it themselves.

For some therapies, such as with those children who have experienced bullying and refuse to go to school because of it, is there a risk the fictional memories become “real” ones? “For VR bullying education, I think the key is to move slowly and carefully with these simulations,” cautions Bailenson.

He stresses VR therapy is in the early stages and that “the right strategy is to build VR content based on social psychology theories, and then to run small experiments based on that content. Based on those experimental findings, one can then edit and improve the simulations. After repeating this process a number of times, under strict attention from a university institutional review board, one can be confident the rewards of the simulation outweigh any possible risks.”

Though we’re a long way off the school pastoral lead using VR goggles to run interventions with vulnerable children, there is real excitement in academic circles that this may be a technology that can really help children to get back into school or to stay in school for the long term. It seems that, far from trying to recreate the classroom, VR might be the way to get children back into real-life classrooms.

This article originally appeared in the 24 July 2020 issue under the headline “Ending school refusal is a virtual reality”