COVID-19 Q&A: Dr. Kim Bullock on Therapy via Virtual Reality
With person-to-person gatherings suspended because of the Coronavirus pandemic, technology has become the lifeline for friends, family, businesses, and care providers. But even before telehealth was in the spotlight, some health professionals were utilizing the unique characteristics of Virtual Reality (VR) to deliver, and enhance, treatments. Dr. Kim Bullock, Clinical Professor of Psychiatry and Behavioral Sciences, is one of those pioneering doctors who embraced VR early on. In this Q&A, she elaborates on how it can offer particular relief for those suffering under the stress of COVID-19.
Let’s begin with how Virtual Reality is used in mental health care, and what makes it uniquely effective.
Dr. Bullock: Sure—it’s a pretty broad subject, so if you are a real geek and want all the details you can watch my talk for the Health Library. Basically, VR has been used in mental health for more than three decades and, generally, in these three ways:
- Skills training and education. People usually retain information learned in VR better than in a purely written or oral format, such as just watching a lecture. So, VR can be used as a platform to teach skills related to mental health. This might come in the form of receiving psychoeducation about a diagnosis or learning skills that help with symptoms, including mindfulness, diaphragmatic breathing, progressive muscle relaxation, social and interpersonal skills or other cognitive strategies/
- Exposure and Simulation. VR is also used to simulate experiences, creating a virtual trigger or prompter for a patient’s desensitization work. For example, if someone is afraid of driving on the highway, they can practice that activity in a simulated driving environment and desensitize to it—before trying it on their own in reality. This can make facing the fear in real life much more comfortable and effective. This practice includes cue desensitization, habituation sensory desensitization, and stress inoculation.
- Distraction. Finally, VR is used to help patients distract and tolerate painful events in the short-run—so these can be things like pain during or after a medical procedure, painful emotions or urges, such as wanting to smoke when quitting tobacco. It can also be used to stimulate people who are sensory deprived, such as older adults, or people who are withdrawn due to depression.
Because of its ability to put a patient in any setting for therapeutic purposes, how might VR be used in the context of this pandemic and the stress and fears it is exacerbating?
Dr. Bullock: Stress and fear are quite individualized concepts and multifactorial in nature. But if people need a distraction from real life, or a palliative approach, then VR experiences could be used quite effectively. These immersive experiences highjack the senses and attention, making it easier not to wander back to thinking about our problems, stressors or negative emotions. Additionally, the loss of many pleasurable activities in a COVID lifestyle can lead to stress, which can lead to a depressed mood, which can zap a person’s energy. Adding sensory stimulation in VR can combat the stress that low energy and mood can cause.
Psychoeducation about COVID and ways to cope with the pandemic to help decrease fear and stress could potentially be taught through VR. When we have full knowledge about a topic, we usually feel more in control. Here’s one example of VR being used in education from the New York Times.
With social distancing and a suspension of in-person appointments, telehealth is getting a great deal of attention and is being utilized more than ever before. How does VR fit into this?
Dr. Bullock: If a patient can take home a headset or have one delivered to their home, VR therapy can be provided even when visits are done remotely. A therapist can control the experience from a distance. Mobile VR devices also allow patients to practice activities or skills between sessions, or on their own.
The other thing to note is that, currently, a tiny number of practitioners are using VR platforms to conduct remote visits within a VR space. Hence, a patient and a provider would meet together in virtual space—both individuals would be in VR, rather than just the patient. In this instance, VR is the platform for delivering telehealth. Usually, these are non-embodied experiences in 2D on a computer screen, but they can also be on platforms where the patient and provider embody an avatar of their choice, in an environment of their choice. This is thanks to development of immersive gaming devices such as HTC-VIVE or Oculus Rift and Oculus Go these experiences for patient provider communication are becoming more feasible.
Although no providers that I know are doing this yet, there is a new technology that is expected to revolutionize telehealth. It involves embodied avatar experiences in what is called Holoportation. It uses very realistic and natural avatars with cameras and 3-D live video. It creates photographic and incredibly realistic real-time simulations by using what’s sometimes called holographic telepresence. This allows meetings between provider and patient which simulate a real meeting by merging real-time video with created environments. This very much like the idea of the holodeck from Star Trek for those old enough to remember the show. This, to me seems like it will have the most potential for telehealth because it will simulate a real therapy appointment where body language and postures and eye gaze can be captured, and the patient will feel like they really have been at a doctor’s office, in their own body.
Who, and what conditions, are best suited for VR therapy in these times of COVID-19?
Dr. Bullock: The most evidence-based reported uses of VR in non-COVID times involve anxiety disorders—but good data exist for all of the below:
- Anxiety (Including Social Anxiety/Public Speaking, Panic/Agoraphobia, Fear of Flying, and Spider Phobia)
- Addiction - for smoking
- Pain - CT for acute pain, burns
- PTSD or Trauma
- Eating Disorders or Obesity
- Autism or Social Skills training
I don’t think the data about the efficacy of utilizing VR for treatment of these conditions would be any different under the added stress of the pandemic — but any condition that might benefit from relaxation, mindfulness, progressive relaxation or breathing exercises may be most easily treated using VR, since these skills are most easily taught using mobile devices.
Is there any risk of VR being used as more of an escape or distraction from the fears of COVID, rather than a medical tool?
Dr. Bullock: Yes. Like any tool used to distract and help us tolerate stress, VR could potentially be overused. But very few cases of VR addiction have been reported. This is most likely because most people become somewhat fatigued and disoriented if using VR more than 40 minutes, so it seems to be very self-limiting. In most cases, we recommend VR not be used for more than 30 minutes per session.
What should patients know about this form of therapy…what should they expect?
Dr. Bullock: VR is not a form of therapy, but a tool of therapy. It can be used in a variety of ways. VR should be personalized to a patient’s unique issues and delivered depending on what is needed. This should be done and delivered only by a trained mental health provider.
And for mental health care providers…what should they take into consideration if they are wondering about incorporating VR therapy into their practice…especially during the pandemic and these times of social distancing?
Dr. Bullock: There are currently no formal trainings or licensing for this tool, nor any current systems of standardized education. Because of this, getting training and supervision from others who have done this type of intervention in clinical settings is very important. Training should accompany any platform a mental health provider purchases.
Joining professional organizations and workshops that provide guidelines on telepsychiatry and the use of virtual and immersive technology in practice is important, depending on the subspecialty of a provider. Standards and guidelines will probably develop more fully as more providers adopt this technology.
Are there any resources you’d like to recommend for patients, and for care providers, as well?
Dr. Bullock: Well-trained mental health providers who may be able to provide Virtual Reality treatments can be found at the Association of Behavior and Cognitive Therapists’ website, www.abct.org, by using the “Find a Therapist” button.