Alexandre Dussaud: C2Care’s VR-based Therapeutic Offerings
Alexandre Dussaud, clinician psychologist working at C2Care, joins Kim Bullock, Jessica Hagen, and Faaizah Arshad to discuss C2Care's VR-based offerings, available environments that address body dysmorphia, the process of working with patients and physicians to build applications, and plans for 2023.
BIO
Alexandre Dussaud is a young clinician psychologist working at C2Care, a VR therapy company that develops softwares and provides online therapy. Trained in CBT, Dussaud helps provide mental health care to C2Care’s patients as well as develop softwares best suited both for patients and therapists. While C2Care specializes in anxious disorders and phobias, Dussaud has a special interest in eating disorders and ADHD.
The following is a transcript of the episode:
Kim Bullock
Hello! Welcome back to Psychiatry XR. I'm your host, Dr. Kim Bullock, and I'm joined by my co-hosts, Faaizah Arshad and Jessica Hagen. Hi guys!
Faaizah Arshad
Hi, Kim and Jessica, so glad to be here.
Jessica Hagen
Hi Kim. So nice to be here.
Kim Bullock
We're so happy to have Alex Dussaud of C2Care as our guest today. Alex is a young clinician psychologist working at C2Care, a VR therapy company that developed software and provides online therapy. Trained in cognitive behavior therapy, he helps provide mental health care to patients as well as develop software best suited for both patients and therapists. While C2Care specializes in anxiety disorders and phobias, Alex has a special interest in eating disorders and ADHD. Alex, thank you so much for joining us here today!
Alexandre Dussaud
Well, thank you for having me. It's really a pleasure to be here.
Kim Bullock
Great. Maybe you could give us a summary or tell us about C2Care and its role in medical extended reality and behavioral health and psychiatry. That would be great.
Alexandre Dussaud
Of course. So C2Care was created in 2015, and the goal at first was to create virtual reality environments for mental health professionals with the guidance of psychiatrists and psychologists. And the first goal was for exposure therapy and phobias. So, we have that middle ground between avoidance and exposure in reality, and sometimes that gap is too big. And what VR really does is fill that gap by adding a step that's easier to get into and learn how to deal with anxiety, to deal with the fear, reduce that anxiety, and then you can step into real life. It started with phobias— many different ones: the fear of driving, the fear of being public, agoraphobia, acrophobia, a lot of them. And then it went out to other mental health issues. So today, we have programs for eating disorders, addiction, to help with depression, with cognitive disorders. So we try to cover a wide range. And basically, when there is a need in mental health that VR can fill, we try to find the right partners to develop that.
Kim Bullock
Got it. Yeah, I stumbled across you while I was looking for more immersive experiences with greater degrees of freedom and movement and embodiment to deliver VR therapy and found your platform. Can you maybe explain how your platform differs or distinguishes itself from other XR psychotherapy platforms or content or competitors, especially I think, Amelia, which is probably the second most used platform?
Alexandre Dussaud
Well, from what I know, the main difference is that our platform offers real interactive environments with a lot of options that you can modify. So for example with the fear of heights, you can choose, of course, the height, but you can choose what type of barrier there is between the patient and the void, whether it is concrete, or a fence, or no barrier at all. For the fear of driving, you choose the speed of the car, how many people are on the road, if the weather is nice or not. So we really try to have multicomprehensive environments in which you can really find all the degrees of difficulty to accompany your patient. Maybe another thing that differentiates us is that we do therapy with C2Care and we send the headsets at the home of the patients, and they get to be accompanied by a clinical therapist training CBT. And they keep the headset at home so they can keep training between sessions. And that really increases the efficiency of the therapy.
Kim Bullock
Got it. Is there any evidence that more immersive, embodied experiences actually help outcomes as opposed to you know, just watching something on YouTube? Do you feel like there's evidence that supports having this more complex, immersive experience?
Alexandre Dussaud
I would not have the name at the top of my head, but I think there are some research that claim that immersion and having more realistic environments where you can actually interact or be more into the environment and not just be a spectator increases your emotional reaction. And that's that emotional reaction that we are seeking for the exposure. So the more immersive the environment is, the higher the probability for the emotion to appear is and for the patient to expose themselves to it.
Jessica Hagen
And you had mentioned that you have a lot of different applications, right? There's a C2Addict, C2Phobia, C2Nutri, C2Hypno. There's a lot of different options that care providers have. How do you ensure efficacy within each of these applications?
Alexandre Dussaud
So each application is developed following the needs and recommendations of the mental health professionals they target. So for example, C2Nutri for eating disorders— most of our environments have been developed to fill the needs of mental health professionals working with eating disorders patients or researchers needing tools to do their research with eating disorders and VR. So it's really because we are following guidelines provided by professionals, the experts in their domain, that we are able to maintain a high degree of efficacy.
Jessica Hagen
So do you work directly with these physicians who are telling you what they need and how it's best to be practiced?
Alexandre Dussaud
Yes, usually, we work with hospital teams that are able to find more financing to develop the tools that they need. We are able to offer low prices because then we include that into the whole suite of softwares because when you subscribe to our solution, you get all the softwares. So it's not just each one gets more expensive. Now you get everything at once. And you get to use everything if you need to.
Faaizah Arshad
And since there are so many applications and environments that clients can choose from, can you talk about whether all of these applications were created at once? Or how has it evolved over time because I know you said that C2Care was started in 2015, so I'm just trying to understand whether the software was developed over time gradually from the limitations of one and then applying lessons learned from that for future applications? Or if it was more of just like from the start, you sort of came out with all these softwares and applications that people could choose from?
Alexandre Dussaud
So I wasn't there back then. But from what I know, it was created over time. It's really better to start small and then build on what you've learned. But even our oldest application, which I think is C2Phobia keeps being updated even today. So we started with C2Phobia, and then we added more applications because more clinicians and physicians came to us saying, “Well, that's really interesting, but I need more of that.” And if that fits in one of the application, we added it. And if it did not, we created a new application for that. And then today, since we do also the therapy, we also love information coming from patients directly— their own experience. So on top of that, now we are able to improve the application to also fit the needs and the specific requirements of patients with their own experience.
Faaizah Arshad
That's really great. So you are taking in feedback from patients and providers?
Alexandre Dussaud
Absolutely.
Faaizah Arshad
How do you attain that feedback? What is the process that you kind of use to figure out where the limitations are or the benefits of the software and applying that?
Alexandre Dussaud
Well, for the providers, the mental health professionals, when we work with them, we try to stay in touch as much as possible. So every six to nine months, we have a long meeting and see, “Okay, what's working, what's not working? What would you like to see changed or added for your needs?” And we take that feedback, we change what we can, and what we cannot change (sadly, sometimes we cannot change everything) but we keep it in our heads and maybe someday we'll be able to change it. And the return from patients? Well, we see the patients directly. We are three psychologists at C2Care and each of us has a set of patients that we treat, and so we have direct feedback from them. And we take that feedback, and we send them to the development team. And we also work with them as clinicians and psychologists using the software to make it as easy to use for the providers and as efficient for the patients.
Kim Bullock
Could you tell us a little bit of the history of your connection to the academic Stéphane Bouchard? I know I had used his in virtuo platform for a while. And I know there's some deep ties between you and that platform and how that developed.
Alexandre Dussaud
Sadly, I don't think I'm the best person to talk to you about that because it happened before I arrived in the company. What I know is that today we are able to provide in virtuo for professionals who need it. It comes with the package with a wired headset because in virtuo only works on computers. But if you have a wired VR headset and you take the C2Care subscription, you also get all the in virtuo environments.
Kim Bullock
Yeah, a lot of his studies kind of established the efficacy in your environments, correct?
Alexandre Dussaud
Yeah, I think that's, that's the case. Yes.
Kim Bullock
And what do you feel like has been the biggest challenge for your company so far?
Alexandre Dussaud
That's a good question. There are a lot of challenges because it's really a big field and I think it's all exploration. And maybe the biggest challenge is to find the people that are motivated enough to work in developing and doing the studies and really pushing back the limits of what we know on VR and how to use VR in something else than the classical anxiety exposure therapy. Because that we know is efficient. You have a lot of studies that show that. And then there are some studies on avatar therapy for schizophrenia, and not enough research on eating disorders and VR. I know we can use it for body dysmorphia and to relearn how to eat. So all the research that's been done in maybe the last 70 years on the whole of psychology now needs to be applied again on VR to see what the limits are, and what it can and cannot do because I really think that's an amazing tool to offer more mental health opportunities to patients.
Jessica Hagen
I think it's interesting that you have this perspective of both the clinical aspect, and then you have the software developer aspect, right? So what type of limitations have you seen from both of those sides that you are really kind of going after to try and squash?
Alexandre Dussaud
I’ll take one from each side. One from the development side is, for example, when you're trying to work on the fear of speaking in public. That requires someone in front of you to speak back. And that would require a very high level of artificial intelligence to make things that are coherent in the dialogue. Or you just have like, pressing buttons, but it does not feel as real as it would be in real life. And so really, from the development aspects, the biggest challenge would be technology levels that would be required to achieve something that's really comprehensive and as close as it gets to fill that gap between avoidance and exposure in real life. And from the patient aspects, I think the biggest limitation is the limits of the human body. Some patients are really sensitive to motion sickness and severe sickness. Some patients do not feel the anxiety in the situations where they're usually phobic. We can still work with that, but they do not see the progress and they get demotivated much more quickly. So that would be the biggest limitations from the patients— that for some of them, sadly, as good as the tool is, it's not for them. And we have to find other ways to do the therapy.
Faaizah Arshad
You've talked a little bit about virtual body ownership and other aspects that virtual reality can be used for. Does C2Care have any offerings like that that are underway, or what projects are you currently working on? Like what should clients be expecting to be coming out, if there's anything new?
Alexandre Dussaud
So we have few environments in C2Nutri that work on body dysmorphia and body image. One that I especially like allows the patient to compare the body that they perceive with the real body by using like a red shadow around the real body. It’s an avatar in 3D, so it's not their real body, but we get as close as we can. And then on top of that, we superpose that shadow to them: “Okay, you see all that red. That's the difference between what your brain sees and reality.” And it really helps with getting in front of the mirror and seeing for yourself: “Okay, what I'm seeing is not real. So I don't have to listen to what my brain says because it's not perceiving correctly.” And we have multiple environments for that: some on the whole body, some on body parts, and some that are just for exposure to your image in the mirror. Because for some patients, just seeing yourself in the mirror causes a tremendous amount of anxiety. So we try to cover a broad range. But as I said, sadly, I think it's one of the fields where there's not enough research on that. And we're working with multiple teams to develop more studies and more environments on that. I'm thinking of one study that's going to start very soon that's working on patients after they get bariatric surgery. So they get their, usually their, stomach reduced or something like that to lose a lot of weight, and they lose a lot of weight. But their brain does not follow the weight loss process because it's happening so fast. Some of them don't look at themselves in the mirror, looking at it happen. So they usually see themselves as still fat where they've lost a lot of fat. And it causes a lot of distress for them. And they're willing to do a study to see how exposure to that through VR can help. So I'm really excited to see the results of the study— maybe two, three years. That's the time it takes.
Kim Bullock
That's what's making me really excited about your company and your offerings is that you have so much of those body transfer experience embodied illusions to use and to work with. You’re the only company I could find to deliver mirror therapy. Yeah, and really leverage these embodied illusions for behavioral and psychiatric care. So for the field of psychiatry, we're kind of the mind and the body, I think you're uniquely positioned. Do you think there's anything else you'd like to say or do you think is relevant for psychiatrists in particular?
Alexandre Dussaud
Well, I think that VR and especially tools that we provide, we do not provide scenarios. We provide a large toolbox. So the environment for the fear of heights can be used for a wide array of other therapies. So it's really important to see VR, not just as a tool for one specific methodology, but really trying to think, “How can I apply that tool to my other patients?”
Kim Bullock
Yeah.
Alexandre Dussaud
“How can I work with that tool for patients with schizophrenia, with ADHD, with depression?” I've seen a meta analysis, well on only four studies, but the results were really interesting. They showed that doing behavioral activation in VR had more positive effects on anhedonia than doing behavioral activation in real life.
Kim Bullock
Wow.
Alexandre Dussaud
And I think it's linked with the fact that VR is playful, even if it's an exercise. And so it activates on pleasure. So the implications of that in the treatment of depression would be really huge if these results would be generalized. So I really think that that's a tool that's on the verge of a breakthrough. And it really needs to be generalized, and we need to start thinking, “Okay, what can I do with it? Instead of what is it offering me right now? What can I take and do something bigger with it?”
Kim Bullock
Yeah, great. What are you most excited about that C2Care and XR is allowing at this point, or in the future? Is there any particular area that you're… I mean, you sound excited about a lot of things. That's great. Anything, anything that you didn't mention, or anything you want to say more about?
Alexandre Dussaud
One thing I really liked, since I've joined C2Care, and we’re trying to develop as much as possible, is long distance therapy. So as I said, our patients, they receive the headsets at home, and you get to do the whole therapy without seeing each other in real life once. But they get that service delivered at their home. And it's so useful for them. So practical. It really opens a new door because mental health, as we know, is not the best part of health that is taken care of. It's often like the last wheel and often forgotten. In France, it's not taken care of by Social Security and that kind of things. And we try to have a price that’s affordable to as many people as possible. And the thing is, we tried to develop that for other mental health professionals to like, if you need just one patient to use VR, while they can subscribe to just get their headset and the software and then it's the mental health professional that you have the control into the sessions. So we really tried to generalize that long distance thing to offer VR treatment to as many people as possible.
Faaizah Arshad
Yeah, I think what you're mentioning is accessibility. And something that I'm curious about is the fact that you've said that since service is delivered at home, there's this long distance aspect of mental health care, but also that in France, mental health treatment can definitely be improved and there's more ways to help patients. So I wonder if you can talk also about where in the world you've seen C2Care products being most used? Have you seen any differences in the ways that your products have been received by healthcare providers in certain regions versus others? Or just in general, in regards to the accessibility aspect, what have you seen like worldwide?
Alexandre Dussaud
Well, sadly I haven’t seen much. Unlike other VR providers, and maybe like, Amelia, we talked about them a little earlier, we are only starting to develop internationally. I think most of our international clients are in the US or close to us in Europe. And I think they're pretty much using it the same as we do at C2Care. Because usually when people contact us to buy our products, they already know what they're getting into internationally compared to when we get clients in France. Sometimes they're just curious. They do want to try it. When you get a call from someone in the US or in the UK about getting that product, they know what they're getting into because they did that research, and they tried to find the best provider for it. So I think they're definitely using it more in an experienced way than in France. We do have a lot of clients but sometimes they just start with it when they get our products. And we do accompany them for that. We do training when it's required, when they need it, and that training is actually really short if you are trained into CBT. And once they get a hang of it, we get a lot of really good returns that it's been useful with a lot of patients. And it's saving them a lot of time and money too because when you have patients that cannot take the subway, well, you don't have to go take the subway with them. You can do everything from your office and have the same results. And it's really accessible to more people, both from the professional and patient side of it.
Faaizah Arshad
Got it. So like one of the challenges is just making sure that the people who are using it are educated about the use beforehand, before they even received the product.
Alexandre Dussaud
Yes, and especially when it's hospitals that get it, it needs to be included in the protocols because I've seen a lot of hospitals that call us back (and you have to go back to do some more training) and they never included the VR in their treatment protocols. So it’s just been used once or twice and then left in a cupboard. So once you get that tool, you need to have an idea of how you're going to use it. Sometimes you won't be able to and that's fine, but really don't think of it as a gadget. It's more of really something that will improve your practice.
Jessica Hagen
What does C2Care really have in store for 2023? Are there any plans as far as new developments or new applications?
Alexandre Dussaud
Right now, since the end of 2022 and for 2023, we're really trying to develop the patient side of the applications so that the patient have more autonomy into using the software. So we are creating scenarios for them that have a dramatic difficulty increase. So they don't have to fill in menus and really have the best user experience as possible. We are going to use motion capture to improve our animations for less of that uncanny valley feeling that you can get with the other characters. So I think yeah, 2023 is going to be the year of the user experience.
Kim Bullock
Well, thank you so much for your time, Alex. We so appreciate it and all you do for providers and patients. I know you've helped me with the technical issues over the year with C2Care and all you do that impact and decrease suffering for so many people. So just wanted to give you a big heartfelt thanks.
Alexandre Dussaud
Well, thank you for having me. It was really a pleasure to be here to answer your questions. That's really a subject that I’m passionate about since I've joined the company. It's really helped me become a better therapist too. So I'm really excited for more people to discover it and try it and include it in their therapy practices.
Kim Bullock
That's great! All right. So that's it for this episode of Psychiatry XR. We hope you gained a new perspective on using extended reality and health care. And thank you so much for listening. We'd also like to thank the International Virtual Reality Healthcare Association for its support (IVRHA). And it’s offering our listeners 50% off when you register for the 7th annual Virtual Reality and Healthcare Global Symposium taking place March 3rd – 5th at Penn Medicine in Philadelphia. And to learn more about the conference and register to attend visit health23.ivrha.org and use the discount code psychiatryxr to receive 50% off your registration. And this episode was brought to you by Psychiatry XR, the psychiatry podcast about immersive technology and mental health. And for more information about Psychiatry XR, visit our website at psychiatryxr.com and be sure to subscribe to the podcast and tune in again next month to hear another guest about XR and its use in psychiatric care. You can join us monthly on Apple Podcasts, Twitter, Spotify or wherever you get your podcasts. And Psychiatry XR was produced by myself Kim Bullock, Faaizah Arshad, Jessica Hagen. And please note the podcast is distinct from my own clinical teaching and research roles at Stanford. The information provided is not medical advice and should not be considered or taken as a replacement for medical advice. And this episode was edited by David Bell and music and audio was produced by Austin Hagen. See you next time.