F106 VRx: What has over 5000 studies taught us about the healing effect of VR? (Dr. Brennan Spiegel)
Virtual reality can have a literally healing effect. Over 5000 studies by today have shown the efficacy of VR for pain management, PTSD, eating disorders, mental health, even helping manage pain during childbirth. The FDA provided a special designation for virtual reality as a breakthrough device for managing pain.
So how does VR help deliver babies? “In studies, VR has been used during childbirth, to help with pain, discomfort management, and potentially as an alternative to using spinal epidurals during the procedure. This was tested in a number of patients in a randomized control trial. Women undergoing childbirth entered virtual reality view a view on a beautiful forest. As they breathe slowly in and out, the microphone in the headset can detect their breath. As they breathe in and breathe out, they can for example breathe life into the forest, or change the environment around them. And it's like a form of Lamaze breathing, which we know is very effective for managing the discomfort of childbirth. We were able to show that if it’s used in VR, it can reduce the pain associated with childbirth. Another study at the University of Michigan shows not only does it reduce the pain, but people feel like time goes quicker - VR accelerates the perception of time in childbirth. So some women felt like the experience of childbirth was shorter than it actually was,” explains Dr. Brennan Spiegel a gastroenterologist who directs the Cedars-Sinai Center for Outcomes Research and Education recently published a book titled VRx in which he explains the applicability of VR and looks at this digital therapy from a philosophical and critical point of view.
Which indication gets which VR environment?
With virtual reality, the hardware is not as important as the software, more specifically, what are people seeing, feeling, experiencing, and hearing. This is not to say that hardware doesn’t matter - cheaper headsets carry a higher risk of cybersickness. Leaving that aside, doctors need to pick the right software for the right patient at the right time, says dr. Spiegel and elaborates further: “It all very much depends on what we're trying to manage. For example, for somebody who's had a stroke, and cannot move their hand or their arm, there's very specific software and virtual reality where people can learn how to reuse their arm or their limbs using a form of rehabilitation therapy in virtual reality. That's completely different than using virtual reality for chronic pain. In chronic pain, we want to teach people skills, cognitive behavioural therapy for how to manage their pain, how to perceive their pain differently. We have a whole cognitive behavioural therapy software program with over 50 different experiences. That's different from somebody with acute pain, who might just be at the dentist or are going through a spinal tap in the emergency department. There, we're not going to teach somebody cognitive behavioural therapy, we just want to distract them, put them on a beach, put them in a forest, put them somewhere where they can imagine that there's somewhere else, and just be distracted.”
Can the effects of a VR experience last?
Dr. Brennan Spiegel.
The short answer is: they might. As explained by dr. Spiegel, sometimes people have learned something new in the VR environment that they can take with them outside of the VR. “There was a patient who I was asked to see because she had very severe abdominal pain but all the tests were normal. We used virtual reality in the hospital and we had her swimming with dolphins underwater. And after about four or five minutes, she started to cry. And I said, Oh, is everything okay? And she said, Yes, everything's fine. I think I know why I have this pain. I said, ‘Really? Tell me more.’ And she said, ‘Well, I think it's because of my brother. My brother had stomach cancer. And I think I have stomach cancer too. And I'm going to die.’ And I said, ‘But you don't have stomach cancer, we looked, we put a camera in your stomach, we didn't see any cancer.’ And she said, ‘I know that I know you guys keep telling me that, but I haven't been willing to accept it. But now these dolphins, they're telling me I need to accept it, I need to move on. I could have been in therapy for a year and I wouldn't have figured this out. But somehow these dolphins are telling me this, and I need to move on.’ And I thought to myself, wow, I'm a gastroenterologist, not a psychiatrist.” The experience had changed the way the patient thought about her own body. That's an example where the state of life of the patient did not change, but she had an insight.
This is not the case in all patients of course. “Other times, what we hope is that people can learn that their brain does matter in connection to their body,” says dr. Spiegel. This is not a new idea. As dr. Spiegel says, Buddhist meditation and transcendental spiritual disciplines show that the brain and the mind do have some control over the body, but it's hard to learn how to do that. In contrast, virtual reality allows people to very quickly discover that their mind matters. And sometimes that discovery alone can help people have sustained lasting benefits.
Psychedelic VR?
Because VR causes an altered state of consciousness its effects are compared to the effects of psychedelics. While psychedelics are still controversial and illegal today, the growing amount of paper showing their therapeutic effects has prompted several entrepreneurs and research to try to turn psychedelic substances into a pharmaceutical form with exact dosage and indications. Given the proof of the therapeutic effect of an altered state of mind with VR, could that indirectly affect the perception and legality of psychedelics? It just might, says dr. Spiegel explaining that there are research projects of combining the two. In this research cases, people on psychedelics can also use the cyberdelics or use virtual reality. One of the biggest risks of psychedelics is an uncontrolled experience, a “bad trip”, caused by an uncontrolled environment. The idea of a set and setting with virtual reality is that it could standardize the experience a little bit. A standardized visual experience might help smooth out the psychedelic experience.
Some psychologists and psychiatrists are experimenting with combination therapy of VR in combination with, for example, ketamine, which is a currently available psychedelic that is used quite frequently. “It is not as powerful as LSD, or psilocybin, for example, but does have the same effects as those, just less powerful,” explains dr. Spiegel. “It may definitely open our eyes to the notion of nondual consciousness. Normally we think of ourselves as different from others, there's a duality. I am me, you are you and we're different. But when you break that down with a psychedelic, we might feel like the same person, or I might become a tree, and literally believe that I am a tree, or I believe that I am sound. And it's bizarre, but it happens when our ego temporarily dies. And that is an amazing thing. Because by dying, you can come back to life stronger and recognize that, you know, you may not be as alone as you think. And you may not be necessarily as important as you think. That insight can be brought to us through virtual reality to some degree if it's used correctly. Not everywhere, not every time, not necessarily as powerfully as a psychedelic, but we can touch that insight. And that alone can be very powerful. And last long after the headset comes off,” says dr. Spiegel.
Tune in for the full discussion:
Some additional things mentioned in the discussion
Because virtual reality is a therapy, then we need a VR pharmacy.
Age can be related to the efficacy of the therapeutic effect of VR. An older person without a prior VR experience might react much differently compared to someone that's younger used VR for gaming.
Like any effective therapy, in medicine, there's potential for side effects. Examples include cyber/simulator sickness. In children it can create false memories where a child believes he for example actually swam with a whale.
A formal designation by the FDA of the science and the evidence of VR is a good sign that insurance companies may begin to take VR seriously and start paying for it. That will be what will determine the future of virtual reality.
Questions addressed:
How does VR help deliver babies?
If you go to holiday, you can feel great when you are away from your daily stress. But when you come back, the stress slowly or quickly crawls back in, since the environment you left and come back to is the same. Similarly; VR is different from everyday reality - so how do you make the positive effect happening in VR last?
There are several indications for VR therapy - pain management, lowering blood pressure, treating PTSD, eating disorders, mental health, …. How do you figure out which landscape should serve for what (pain patient flying above fjords)? Can you take us through the therapy design discovery journey? (Perhaps it would be good if you could mention any statistics here about the efficacy studies)
What is the role of the type of headsets you use? The industry has diversified, there are several types of sophisticated equipment and there are cardboard glasses one can use with an iPhone.
How do you determine, which patient will go on VR?
I’m sure many listeners will wonder “Where can I get access to this therapy”? Is accessibility atm mostly difficult, since not many medical centers specialize in this kind of therapy?
How would you assess VR medical research across the globe? Does research differ, are researchers focusing on different things in different countries? (can you try talking through examples, if you are familiar with them?)
It is fair to mention that VR can also have negative side effects. Confusion of children and the elderly, nausea, rekindling of memories … How can one avoid these negative effects?
Several times in the book you mention how VR does in some aspects have similarities with psychedelic experiences because both approaches cause altered states of consciousness. A lot of research is being done in the medical use of psychedelics, pharma startups are working on producing stable strength and doses of psychedelic compounds such as psilocybin which can be found in magic mushrooms but with those you can’t really be sure about their precise strength. Anyway - what does in your opinion VR research mean for psychedelic research and approval?
VR has many different indications and takes time to understand. You are a gastroenterologist by background and have spent years studying the use of technology for very different indications. What does the use of VR mean for doctors as professionals? Will there be a VR specialization for doctors in the future, so there will be more doctors like you, or do you think VR will be just one of the therapy options doctors will know about and be able to prescribe?
In the end, VR is therapeutic. Where do you see the role of pharmacists in the story? How does one assess interactions with other medications?
VR research is two decades-long and by today we’ve come to a point where the equipment is more or less accessible. What’s the next step that will make it more widely available? Is it the awareness of the physicians? A payment model that would support the therapy? Accessibility of landscapes/programs? Are there already libraries to choose from similarly as you can choose a guided meditation in an app?
How big is your library of VR therapeutics?