The Therapeutic Value of Virtual Reality
Albert “Skip” Rizzo is director for Medical Virtual Reality at the University of Southern California-Institute for Creative Technologies. He’s also known as a pioneer in the therapeutic use of virtual reality, using VR to treat PTSD, depression, addiction, anxiety disorders, pain, autism, sexual assault trauma, and fears of everything from public speaking to spiders.
So what makes VR different? Rizzo cautions that VR and psychedelics are very different: “It’s sort of really inaccurate to compare VR with the psychedelic experience. You wouldn’t compare watching a movie to a psychedelic experience.”
Yet there are similarities, especially in the therapeutic framework: “Set and setting are so, so important,” says Marcela Ot'alora, principal investigator for phase two clinical trials in MDMA-assisted psychotherapy. Ot’alora points out that when somebody says "this particular therapy saved my life," it’s the therapist who was able to support him or her through the process.
When it comes to treating PTSD, Rizzo’s work revolves around VR-based exposure therapy. VR has the capacity to create simulated worlds that allow a person to suspend disbelief, and put them into a manufactured scenario much like they experienced when the traumatic event occurred. A patient describes the traumatic experience to a clinician who can also control the VR world—think changing time of day, or adding gunfire or a helicopter to a war scenario—and who also sees the experience on a screen while the patient is wearing a VR headset.
The VR environment is created by someone else, and the user experience is created intentionally to be emotionally evocative and stimulating, in order to help them review what they went through, and hopefully move past it. “We’re trying to activate anxiety in a safe place, so the fear of these stimuli extinguishes. So the therapist has to constantly monitor the patient to make sure they’re engaging with Iraq or Afghanistan or sexual trauma in a way that is healthy, not over the top, and not too provocative for them.”
With, for example, MDMA for PTSD, the patient is taking a drug. “Someone with PTSD, the trauma is there all the time. It might come up in a different way than you imagine. But it comes up,” says Ot’alora. Therefore there’s no need with MDMA psychotherapy to evoke the trauma.
In an MDMA psychotherapy session, the therapists work in a controlled, therapeutic environment, but trust that MDMA will bring up what needs to happen in that moment, so that the patient can then work towards healing themselves. The therapist is supportive, with no judgment, and fosters a place where the patient can experience and fully process the emotions of the experience.
Reliving the experience this way, in both VR and MDMA-assisted therapy, with a trained and ethical medical professional, can be incredibly therapeutic, especially over time. The same kinds of clinical skills and techniques can be applied in both types of therapies, Rizzo says.
And that is precisely the similarity: Altered states therapies, regardless of whether VR induced or drug induced, are reliant upon that trained medical professional.
And just as you wouldn’t counsel your friend who has been through a rape or war trauma to go to a rave and take MDMA, Rizzo says VR should be respected the same way, and used therapeutically in a therapeutic environment with trained clinicians.
“I’m not so keen on self-help, and just having them self-diagnose and download some software,” he says, pointing to the age-old saying, “He who defends himself in court has a fool for a client and a fool for a lawyer,” and notes, “Self-treating is the same.” Someone who self-treats, he says, is at risk.
Rizzo thinks the VR headset will be like a toaster: Every home will have one, but it won’t be used every day. But he thinks it shouldn’t be used to self-diagnose or treat mental health or any other medical issue.
As with psychedelics for therapeutic use, “It’s important, whenever you’re doing therapy, someone has to be well trained, and know why they are doing it, and how to preserve the safety and integrity of the patient,” he says.
Both stress that a well-trained clinician is able to handle different issues that come up.
“With VR, it’s an emotionally evocative technology, and yes it can work for good because of that. We’re doing a study now that mimics the locations where sexual assault is happening in the military. It is emotionally wrenching when people go in and navigate these spaces. I can’t imagine that going in without a guide that this is gonna heal you from your rape.”
Rizzo stresses the importance of safety protocols that are well defined in MDMA therapy as it works its way through the drug approval process.
But Rizzo sees the quest to self-treat as being potentially problematic in the unregulated world of VR. “In some forms, fear of public speaking is a diagnosed thing. Most people have that until they do it a few times and practice.” But there are a number of different companies selling different kinds of fear-of-public-speaking VR software.
“Now that has happened, but no one is squawking about it. But once you start accepting things like that, it becomes, ‘oh it’s just fear of flying,’ or ‘oh it’s just fear of heights.’”
Yet with psychedelics, he points out, no one would say, "Oh, you’re afraid? Why don’t you go to a rave and try MDMA and see if that helps you?"
The power in these therapeutic experiences, whether VR or psychedelics, he says, is that with the right support, with an ethical clinician, and highly supervised and well-trained people, you can heal.
“We need to make sure it’s ethically applied,” he says, so as to protect both the safety of a person and their mental health.
And both psychedelic therapy research and VR therapy have rigorous screening processes that are requisite, as not every therapy is right for every person. For example, evidence suggests that a female who gets motion sickness and is ovulating is probably not a suitable candidate for VR therapy at that time. VR side effects may include temporary nausea, ocular strain, sleepiness, and disorientation. With MDMA, someone with a heart or liver condition probably wouldn’t qualify for the therapy, and a side effect might include tightness in the jaw. And of course, there are therapists who don’t support VR therapy or psychedelic therapies.
Another way VR differs from treatments like MDMA, for example, is that there’s currently no oversight like the FDA and the DEA in research and use of pharmaceutical drugs or psychedelic therapy. That could change, says Rizzo, if software companies make ridiculous claims, and VR is looked at as a medical device.
A more pressing challenge to VR therapy, though, is that many people still don’t know about it.
“I think we’re a couple years away from common, mainstream use. However, there are hundreds of therapists around the world using it now, and there are companies like Virtually Better… or Psious, that make exclusive VR software to treat fears and other pathologies for clinicians.”
In addition to exposure therapy, like with PTSD, VR can also be used to distract the patient, such as when they are going through a painful procedure. While it’s not so effective for chronic pain—“you can’t wear a headset all day,” but, “Maybe you can teach things in the VR context that are easier to teach in VR that can help with chronic pain.”
VR can also motivate—using the game-based content to motivate people to do cognitive or rehabilitative activities. And VR lets clinicians measure progress and test ability as the patient evolves.
While Rizzo works to promote guidelines for the safe and ethical use of therapeutic virtual reality, Ot'alora is looking forward to starting phase three of the MDMA for PTSD clinical trial, and to multiplying their positive results across the country. “We hope to start that in spring of 2018. That will be our last phase, and if all works well, we can apply for MDMA to become a prescription medication.”