Barbara O. Rothbaum: Emory Healthcare Veterans Program and VR for PTSD
Barbara O. Rothbaum, Director of the Emory Veterans Program, joins Kim Bullock and Jessica Hagen to discuss virtual reality therapies for PTSD, psychopharmacology and psychotherapy, Virtually Better that is a company co-Founded by Dr. Rothbaum, and the purpose of the Emory Healthcare Veterans Program.
The following is a transcript of the episode:
BIO
Barbara O. Rothbaum, Ph.D., ABPP is a professor, Associate Vice Chair of Clinical Research, director of the Emory Veterans Program and the Trauma and Anxiety Recovery Program, and the Paul A. Janssen Chair in Neuropsychopharmacology in the Department of Psychiatry at Emory School of Medicine. She is a past president of the International Society of Traumatic Stress Studies, a pioneer in the application of virtual reality to the treatment of psychological disorders, received the Lifetime Achievement Award from ISTSS and was a member of the Institute of Medicine’s Study on Assessment of Ongoing Efforts in the Treatment of PTSD.
Kim Bullock
Hello, and welcome back to Psychiatry XR. I'm your host, Dr. Kim Bullock, and I'm joined by my co-host, Jessica Hagen.
Jessica Hagen
Hi Kim, nice to be here.
Kim Bullock
Today's guest is Barbara Olasov Rothbaum, who is a Professor of Psychiatry and Director of the Emory Healthcare Veterans Program, and Dr. Rothbaum holds the Paul A. Janssen Chair in Neuropsychopharmcology. And she has been studying PTSD treatments since 1986, and she has developed and tested and disseminated some of the most innovative and effective treatments available for PTSD. She is an inventor of virtual reality exposure therapy and was a pioneer in applying it in the treatment of PTSD in Veterans. She has authored over 400 scientific papers and chapters, 11 books on PTSD and edited 4 others on anxiety. She is a past president of the International Society for Traumatic Stress Studies (ISTSS), and was the recipient of the 2010 “Award for Outstanding Contributions to the Practice of Trauma Psychology” for APA (the American Psychology Association) Division 56 and the Robert S. Laufer Award for Outstanding Scientific Achievement from ISTSS. Her most recent book for the public is entitled PTSD: What Everyone Needs to Know. So Dr. Rothbaum, thank you so much for joining us. We're so honored to have you and all your contributions to patients, providers, trainees, the public, we're just so lucky to have you.
Barbara Rothbaum
Thank you. I'm excited to be here.
Kim Bullock
Great. Well, so you've had an amazing and varied career, the theme of anxiety and PTSD and exposure running throughout. We'd love to focus this episode on your interest in virtual and extended realities today. Maybe could you start with telling us how and why you began using virtual reality?
Barbara Rothbaum
Of course! There was a seed grant, and it required an Emory investigator and a Georgia Tech investigator. So a computer scientist from Georgia Tech, called me up. And he makes fun of me, because I said, “You want to do what?”, and this was in 1993. And I can always date it. He didn't know me very well. Part of what I was writing for the grant was due to him on a Tuesday, and I went into labor Monday night. And so, I know how old that kid is— actually he just turned 30. We were just with him for his birthday. And in that very first study, we decided to try virtual reality exposure therapy for the fear of heights. And it wasn't really that we needed a new treatment for the fear of heights. We've been taking people to the top of parking garages for years, and it works just fine. It was really a test balloon for VR, and to see if it would work for exposure therapy. And what we found was that people did get anxious in the VR, that anxiety did come down while they were still in the VR, and 7 out of 10 of them put themselves in real life height situations by the end of the study without us even asking them to so it translated to the real world, which I think obviously that's important. It doesn't matter if you can ride in a virtual elevator if you can't get in a real elevator. And it was effective on all of our measures. So, we were very excited and thought that there were a lot of possibilities which again, that paper was published in the American Journal of Psychiatry in 1995. And it was the first published paper using virtual reality to treat a psychiatric or psychological disorder. So we've been doing this a long time now.
Kim Bullock
Wow! Although that doesn't seem very long ago to me. That’s amazing!
Barbara Rothbaum
Well, if you think about it, conventional wisdom is about 20 years from the time that something gets published in the scientific literature, then it's much more mainstream. And we're more mainstream, but I don't think we're as mainstream with virtual reality as one would have predicted.
Kim Bullock
Right, right. Well, what are you most excited about in the field or in your current projects using extended realities in behavioral health or mental health or anxiety?
Barbara Rothbaum
I love the VR especially, the virtual reality for lots of things. So, I'm an exposure therapist, and I love the VR for exposure. My favorite virtual environment is actually the virtual airplane. And that is because it is such a pain to treat someone with the fear of flying without it. I'm in Atlanta, so probably everybody has been through the Atlanta airport. I actually love it. But it is something to reckon with. And even the traffic getting there is something to reckon with. And if I have to fly with a patient, that's going to take hours, and it's going to be expensive and insurance isn't going to reimburse it. And we've done a number of studies now with the virtual airplane, and a number of them comparing it to using a real airplane to standard exposure therapy. And it works just as well. And we don't need to beat standard exposure therapy, it works. This is just so much more feasible.
Kim Bullock
Yes.
Barbara Rothbaum
We can take off and land as many times as we need to, without leaving my office and all within my therapy hour, and it works just as well. So that's one of my favorites.
Kim Bullock
That is great. You're kind of leading into one of my questions for you about feasibility. So you know, I've kind of taken a broad look at all the literature over the years. And yeah, like you're saying that most of the studies show it's not inferior to standalone exposure therapies. But how do you think we can do our research going forward, so we can show the value of XR and VR for enhancing therapy, like deployment focused models? Or what kind of designs do you think will help us translate and show the efficacy and effectiveness of it, rather than trying to do it head-to-head with some standard?
Barbara Rothbaum
Well, I think that all of our regular clinical trials, methodologies, and using objective measures will help show. We've done a couple of studies now comparing virtual reality exposure therapy to prolonged imaginal exposure therapy. So let me back up a second and just talk for a second about PTSD.
Kim Bullock
Yeah, yeah.
Jessica Hagen
Absolutely.
Barbara Rothbaum
Post Traumatic Stress Disorder… because I treat a lot of PTSD, other anxiety as well. With PTSD, the way I see it is that people are haunted by something that happened to them in the past. And we think that the symptoms of PTSD are all part of the normal response to trauma: nightmares, you know, bad dreams, being scared to go outside by yourself, not wanting to think about it, talk about it, and all that's normal following trauma. And for most people, it dissipates over time. But for a significant minority, it doesn't. And we think that avoidance plays a big role for those that it turns into PTSD. I make a lot of analogies to the grief process, that when we go through something important, or lose someone we love, there's really no way to the other side of the pain except through it. And if we try to avoid it, then that's where it can haunt us and fester and cause problems. So, the treatment that has received the most evidence that it works for PTSD are exposure therapies. And in exposure therapies, what we're doing is helping people confront the memory of the traumatic event and reminders, but in a therapeutic manner, so that they can handle it and it gets easier. The distress decreases, guilt, whatever. You know, all of the associated feelings get better. So historically, we've done that with the therapies called PE: prolonged imaginal exposure. And in that, we asked people to close their eyes and go back in their mind's eye to the time of the trauma and recount it in the present tense over and over and over. We record it and ask them to listen to it at home. So, what we do in VR (in the virtual reality exposure therapy) is pretty much exactly the same thing, except that their eyes are open and the therapist is matching what they're describing, in the VR. And so, I direct the Emory Healthcare Veterans Program. And so for, as you said, deployment related PTSD… for example, if somebody is saying, driving back to base, hit an IED right front, everything fills with smoke, we can recreate that. And we can do it over and over and over again, until their bodies and their brains register, “This is just a memory,” and it's not the level of threat that it feels like.
Kim Bullock
Yeah, I spend about probably 30% of my week delivering the treatment that you developed to civilians, mostly women. And one thing I really was burning to ask you is… because it's so idiosyncratic, the types of experiences that have caused PTSD for my population… and I wondered why (or maybe I'm not aware of them) the RCTs really focused on using VR for the imaginal exposure, and not using it also to enhance the in vivo part of the exposure. Because to me, it's like 50/50, you know. The exposure is the imaginal. And then there's the in vivo, which is the things that they're avoiding in their day-to-day life. They have to do with the memories, but they're confronting their life and the cues. And those are the things I find — that I'm using them more often to help them with the in vivo exposure, rather than the imaginal exposure. Hope that makes sense.
Barbara Rothbaum
Yes. No, and I love hearing that you're doing it. And I love hearing that you're being true to the therapy and being able to innovate to help your patients get what they need. And you're right. That's actually an interesting question I've never really thought about. We've thought about it in PTSD, more for enhancing the imaginal exposure, but didn't really think about it for using it for the in vivo exposure, although for other types of anxiety disorders— you know, fear of heights, you know, fear of flying— I mean, obviously, that's more for the in vivo. Now we do also use the VR in an activation paradigm to measure people's physiological reactions. And so, I love it for that, because you can ask somebody how they're doing. But this is in some ways bypassing that and asking their bodies how they're doing. And we've been able to show before and after treatment decreases, and the psychophysiological startle and heart rate and skin conductance to these very activating cues. We've created three, two-minute standard VR clips. And we embed acoustic startle probes within them. And then we have blue screens in between with acoustic startle probes. And so that's how we're able to measure startle response. And we refer to it as fear-potentiated startle because it's in this activating environment. And you may not realize it, but anytime you startle you blink your eyes. And so, we're able to measure it with just some electrodes right under the eyes. And like I said, measure heart rate and skin conductance, and we're able to show the decrease in the body's reactivity following treatment.
Kim Bullock
Yeah, it's so cool, this merging of technology and VR with the biological markers. Oh, and that brings up even though you're a psychologist, you're into psychopharmacology, just like I'm a psychiatrist interested more in psychotherapy. But I wondered, as far as your studies using enhancers like the D-Cycloserine and MDMA. My question was to looking at your very well-funded RCTs. And I know you have really good rationale. You're an amazing scientist. And I wanted to know what the rationale was for including all the different arms with the enhancers rather than just looking at VR in a randomized control trial for PTSD. What made you add D-Cycloserine to the studies?
Barbara Rothbaum
So, the first study that we use the D-Cycloserine and used the VR was published in 2004. We did it for the fear of heights. And that was really a test of D-Cycloserine, which is an NMDA partial agonist, not to be confused with MDMA that we also will talk about. And my colleagues who are animal researchers found that the D-Cycloserine facilitated the extinction of fear. It's an old tuberculosis drug. It's an old antibiotic, so it had been FDA approved for like 50 years, so we could use it in people. We decided to use the VR because usually in studies, including a psychotherapy component, methodologically, that's a lot softer component. So, the way you do therapy with your patient might be different than the way I do therapy with my patient, and it introduces noise. And so, we decided to use the VR because we could exactly control the exposure therapy and the psychotherapy component. We could make sure that every single patient got exactly the same exposure to height situations for the same amount of time, and back when we did that study, pretty much be assured that they weren't going to be exposed to it outside of our experimental conditions (so out of the drug conditions). And in that study, we under dosed the exposure therapy to allow the D-Cycloserine to augment it, to facilitate it if it was going to. And it sounds like you know that at the beginning of that story that the D-Cycloserine did facilitate the extinction of fear. It did augment it. And when we brought people back three months later, we saw the same results— that the people who received the D-Cycloserine were significantly less on avoidance and anxiety and again, had had put themselves more in real life heights situations without us asking them to. So, it helped translate into real life. So, I really started liking the virtual reality for the methodological control.
Kim Bullock
I see. So you are more focused on the D-Cycloserine rather than the efficacy of VR, right?
Barbara Rothbaum
Right.
Kim Bullock
Ah! That makes so much more sense.
Barbara Rothbaum
Yeah, at that point, we knew that the VR worked for fear of heights.
Kim Bullock
Oh!
Barbara Rothbaum
And so, we wanted it for the methodological control that it would offer in testing the D-Cycloserine.
Kim Bullock
Okay, and I guess I was talking about the PTSD study, then, and the D-Cycloserine didn't seem to have the same results, right?
Barbara Rothbaum
Right. Well, it didn't, except on the psycho physiological measures, the more biological measures, which are the more translational measures: then in those cases, the D-cycloserine did show more efficacy on startle response, salivary cortisol, again, the more translational measures. On the more clinical measures, the results reinforced what a lot of us who do exposure therapy think in that the benzodiazepines interfered. So, the only significant findings were that folks that got the alprazolam (the benzodiazepine) did worse by post treatment and three months afterwards on different of the clinical measures. So again, I don't think the benzodiazepines are a great treatment for PTSD, and certainly not when you're doing exposure therapy.
Kim Bullock
Oh, that makes so much more sense that you were studying the drugs and its effect, and you were assuming the VR was as effective as the non VR because I think I run into people that do PTSD work, and they're like, “Well, that study showed that the VR isn't any superior.” Or it seems like it's still out there with some of the PTSD clinicians that they still need to be convinced that VR is enhancing the therapy in order to use it. There's still barriers to accepting its use. So yeah, I don't know if you think that's a problem, or it's just the ones that I'm running into that are saying that.
Barbara Rothbaum
Oh, yeah, no, it definitely is. But you're right, that those studies were designed really to test the pharmacotherapy and to use the VR, and be able to control it and hold it constant. And if you look, just the effects, I mean, overall, therapy was effective, people got better and improved. But if you look at the different drug groups, that's where you find differences. Yeah, it wasn't really set up to test the VR.
Kim Bullock
Test the VR for PTSD.
Barbara Rothbaum
No, I think you're right. I think that's part of why VR hasn't caught on more. So, one, if you back up and just think about dissemination, so most clinicians do what they were trained to do in their graduate training. So, it's really hard to get people to do anything new or different. And then there's this whole dissemination science that has looked into what is required to get people to do something different. So, to get them to do something different, that then also requires technology, which they might be uncomfortable with and that costs more money, for a lot of people: “Why would I?” If my practice is full, and I'm busy, my patients seem to be getting better, why do I need to do anything different? And certainly, that would cost me more money.
Kim Bullock
Okay, I'm hogging all the questions. Sorry, Jessica.
Jessica Hagen
It’s okay. Actually, that's a good transition to my next question is, how does virtual reality lend itself to psychiatry and psychiatric treatment? What benefits do providers and patients get from VR that they wouldn't otherwise get?
Barbara Rothbaum
So I could talk about this for four days. I won't. I'll try to make it brief. One, like we said (that I think the perfect example is the virtual airplane) is just feasibility. And that's the very biggest advantage, you know. I can treat the fear of flying in my one-hour therapy session without taking all day long and flying with somebody. The other that we've talked about is the methodological control. So even for example, with the fear of flying, if my patient's not ready for turbulence, I can guarantee there won't be turbulence. When my patient is ready for turbulence, I can guarantee there will be turbulence. So even within a therapy session, I have control over the stimulus that you don't in real life. When you're talking about doing it for research, I love the methodological control. I also love it as an activation paradigm. So especially in PTSD, in psychiatry, in general, we don't have a lot of objective measures. A lot of what we do is based on patient self-report, and I love looking for more objective measures of problem and of treatment response. And so, I think that virtual reality is a great activation paradigm. You can put somebody in the situation and measure different biological responses and see how they're responding. I think it can help diagnostically. I think it can also help seeing how someone responded to treatment. Something that I haven't done, but I keep wanting to do is, for example, with military populations when they return home from a deployment, people have learned since the Vietnam War. And I mean, that's when PTSD became a diagnosis in 1980, really in response to the large number of Vietnam veterans. And so, the Department of Defense has learned and so they tried to assess people as soon as they come home. Well as soon as people come home, they want to get to their families. They don't want to sit around talking to the Docs. And I've been told that the questions they asked, enlisted people call it an intelligence test, and only dummies answered them honestly. Because if you say you're having problems, then you're delayed. Then you got to meet with the Doc. You got to do different things, and you don't get to see your family. And I think a lot of people also when they come back home, they have just been missing home, they've been scared 24/7 over there, and they think everything's going to be better when they get home. So, I think they have hope. But I think we could use the VR and an activation paradigm to assess them, and maybe be able to predict, who's likely to reintegrate just fine, and who might have some issues and could use treatment. And we do have effective treatments. By the time we see people in the Emory healthcare Veterans Program, they've been home approximately 10 years, and that means they've been suffering for 10 years, and then all of the sequela to PTSD. So, we've got a lot of substance use and misuse problems, a lot of failed marriages and relationships. So, if we could catch people sooner, we might be able to treat them effectively and avoid all of the sequela. Ah, so I know I just gave you a very long answer.
Jessica Hagen
No, that was fantastic. And to kind of move forward a little bit on that. So, you've written books on cognitive behavioral therapy for PTSD, reclaiming your life after a traumatic event, pathological anxiety, anxiety disorders? How does the effectiveness of virtual reality enhance therapy differ among these conditions?
Barbara Rothbaum
I think it depends on the person's and the condition. So, for example, for PTSD, as I mentioned, PTSD, I see it as a disorder of avoidance. And that includes in treatment. So sometimes, you'll come across somebody who can talk about it, seemingly pretty easily. And what you realize is they've cut themselves off from their emotions. So, they're not really accessing their emotions. And then they're probably not going to get better because that's what we think you need to do to process those painful emotions. And especially in military populations, so they're trained to avoid. You don't want to have a big reaction in a war zone. You want to do what you were trained to do. But at some point, you need to be human and to process it and put it all back together. And I love the VR for military populations and PTSD, because they are so avoidant, and it is such an evocative stimulus. It's hard to avoid, and people pay so much attention to the visuals in VR. For a lot of my Veterans, I think it's the sounds, that it's really very evocative. We've also got people on a raised platform with a base shaker underneath. So for example, they can feel the vibrations of the Humvee engine, they can feel the vibrations of the explosion. So it's so evocative. You're thinking it and you're back there in your mind's eye. You're seeing it match. You're feeling it. In some cases, you're smelling it. You're hearing it, and it's harder to avoid. So, for military and PTSD, I think it's because it's so evocative. For some others, I think it's a great first step. In that first study we did with the fear of heights, one of the people that participated— a young man— he said, “I knew what I needed to do was expose myself to height situations, and there was no way that was going to happen.” I mean, yeah, that's the nature of the problem. And so, I think it's a more acceptable first step for some people that they can know their feet are firmly planted on the ground, but it feels like they're 50 feet in the air. And then by the time they get done with treatment, they're okay going 50 feet in the air. This particular guy, at the time, it was the tallest building in the southeast here in Atlanta and it had a restaurant on the top and his friends invited him for a drink at the top and it's a glass elevator, and he got on the elevator and got back out and he walked up to the top. And he said that was the point that he realized, “I need treatment, this is interfering with my life.” And then by the end of treatment, he invited his friends for a drink up top there and he rode the elevator with them again without us asking him to. So I like it for the ease. I like it for the acceptability for patients. Greg Rieger did a study years ago in active duty military, and asked, “If you were going to get treatment, what would be more acceptable to you: talk therapy or VR therapy.” And VR therapy was more acceptable. I think, especially to a gaming generation. I also think for some people, it's a minority, but I've seen it over and over again, some people looking at me, they have a hard time talking to me. They put on the VR head mounted display, and they turn into Chatty Cathy, and you take it off, and they have a hard time talking to me again. So, I think for some people, it seems to facilitate their communication, but that's probably just a minority.
Jessica Hagen
So, there’s pretty good patient reception to it.
Barbara Rothbaum
Yes, sometimes there'll be somebody it's like, oh… because it's not as good as if they really are gamers. It's not as good of graphics. I mean, nobody's putting millions of dollars in it, like they do the games. And so occasionally we'll have somebody say, “Oh, you know, this is too pixelated” or something. And, you know, we'll just ask them, “Try to just suspend your judgment. Try to just get into it.” And then usually within several seconds (30 seconds at most) they're able to get into.
Jessica Hagen
Absolutely.
Kim Bullock
Yeah. And we haven't even touched yet on your entrepreneurial spirit. I mean, it's just so amazing. You're this powerhouse clinician, academic, writer. And then you also started a company. And I wanted to ask you about one, how did you have the time and ability to even do that with all the other millions of things you're doing? And then how did you structure it? How do you maybe… conflicts of interests…and that can be kind of tricky? And then anything else you'd like to say?
Barbara Rothbaum
Yeah, so when that first paper was published in 1995, in American Journal of Psychiatry, there was a huge response. And Emory and Georgia Tech thought there could be a marketable product and literally took us to the lawyer to incorporate and that's Virtually Better… my conflict of interest. And so it's a Emory/Georgia Tech startup company. And about a week later, I got a letter in the mail— we still use mail bin— and said, I had a conflict of interest with Emory. And I had almost a little panic attack. I thought, “Am I dirty? What does this mean now?” And then actually served on the conflict-of-interest committee for six years and learned how to manage a conflict. I am full time at Emory, but I am a part owner in Virtually Better and I usually disclose, disclose, disclose all over the place. And that's one way to manage the conflict. I was allowed to do the virtual reality research with Virtually Better at an early stage. But as soon as things got to phase two, Emory said, “Okay, you've got to stay now at arm's length from it.” You can help design it. You can help do different things. But there's certain things that you can't do and don't touch the data and all that kind of stuff. And you know, actually, at this point, I don't have any funded VR studies, I think. So, Emory is not considering it's still a conflict of interest, although I still disclose it as one because I think it's easier just to disclose it. But yeah, Virtually Better has been around for a long time and creates VR for mental health. And so it's, for me, it feels like just a wonderful asset. You know, I talked to people about it, and it's like, “Okay, yeah, there are ways to do that.” And we've been criticized that it's run more like an academic department than a for-profit company, but I'm an academic. So, we've been able to do small business grants through NIH and work with a lot of other researchers around the country and around the world that way and partner with them. So, it's been, it's been a lot of fun.
Kim Bullock
Oh, yeah. Virtually Better was the first platform I tried before COVID. I don't know how much you're involved with the company now or not? And has anything changed or morphed or adapted to telehealth? Because now we still are not back at the offices. So, I can't use the old setup I had with Virtually Better.
Barbara Rothbaum
So Virtually Better does other stuff too. We're working on an app with them trying to help… Well, it was really we’re funded for frontline health care workers during COVID but for anybody trying to help them process if they've been through difficult or traumatic experiences. So, we're testing that app now called Messy Memories, and hopefully it'll be useful and if so, we'll be out there. Yeah. So Virtually Better does a number of different things digital.
Kim Bullock
Okay.
Barbara Rothbaum
Yeah, I think that you're right though. I think that we do need to adapt and figure out how to do it because head mounted displays are coming down in price so much that really soon it would be feasible for patients to have their own head mounted displays. And if we could treat them, you know, via telehealth. So, we haven't gotten there yet. But I think that that is absolutely where we're going.
Kim Bullock
Yeah, well, it seems all the platforms are trying to get creative.
Jessica Hagen
As VR technology progresses, what should all of these different stakeholders, what should developers, VR users, healthcare providers, and any other VR stakeholder, be cautious about? Is there anything that makes you nervous about where VR is heading?
Barbara Rothbaum
Oh, of course, that's my job. As a Director of the Veterans Program, as I said, my job is to figure out how anything can go wrong and try to preempt that. So, I think one being precise about our language. So, a lot of people call things VR that aren't VR. Anything that's delivered in a head mounted displays is not VR. People will deliver a video in a head mounted display or watch TV. That's not VR. And so, I think being precise about what is and what isn't. I think if you're putting something out there, one of the advantages that I've had working with Virtually Better and as a clinical researcher, before we put anything out there, we've tested it. And generally, we have a treatment manual because I believe in evidence-based medicine, whether it's VR, or pharmacotherapy, whatever it is. We need to deliver something with evidence and in the way it was meant to be delivered. And so, I think that applies to VR, just like anything else. And bad VR therapy is just bad therapy. I don't want someone who's not trained in exposure therapy, getting access to the VR and thinking, “Oh, boy, now I can do exposure therapy.” It's a tool, and people should only use it if they're trained in exposure therapy, and then they have to be trained on this technology and how to incorporate it. So those are probably my top three concerns.
Jessica Hagen
Yeah, just making sure that everybody is understanding what exactly needs to happen within VR and understanding what the purpose of it is.
Barbara Rothbaum
Right.
Jessica Hagen
Absolutely.
Kim Bullock
Well, I have one last selfish question. So, for those of us who think we have an idea of how to use VR to enhance an evidence-based treatment… and you know, you hobble around, you get some money to do an RCT, and you show it's not inferior than doing it alone, maybe there's some signal that it might even be superior… the next phase for scaling. Because we know that we've been disappointed by these RCTs that then fail to scale. I'm kind of at the next point of like, how do you design a study in the wild? I have a clinic where I could do all sorts of in-the-wild studies, what would be the perfect design really showing that you could scale a treatment or innovation or an enhancement to an evidence-based psychotherapy?
Barbara Rothbaum
Yeah, that might be a different design. It might be more of an effectiveness design than an efficacy design. You know, at that point, you've shown that it helps. And how do we get it out there? And using some of the dissemination science bits, you've got to make it feasible. You know, so, you've got to make the…
Kim Bullock
How do you prove that? What are the outcome measures we should be looking at?
Barbara Rothbaum
Well, it depends exactly what you're looking at? Or do you want to enhance the feasibility for your providers or for patients? So you know, it can just be number of sessions, or dropout? Or retention in therapy? Or use of, you know, if somebody has the choice? Which one should they choose? Or if they get to use both? And then which one, you know… kind of like they do the peanut butter tests, you know… taste both, and which one do you like better? And then I think, at the end of the day, they're probably going to be certain patients that do better with the VR, and then certain patients who probably don't need it. And that's going to take bigger studies to show those differences. We've just published a paper —well, in 2022— and with Skip Rizzo and Joanne Difede, comparing the VR to PE for military folks. And in general, they were both effective. It gets complicated. Folks were depressed, they did a little bit better with VR. And so, I think it's going to take large samples to try to figure out which treatment for whom. But like you said, in some ways, you want to disseminate it widely, so that people have access to it if they figured out it would be helpful for this patient or it would be helpful for, for their practice.
Kim Bullock
Well, thank you. Is there anything else you'd think listeners and a psychiatrist especially maybe need to hear?
Barbara Rothbaum
I've got to plug my Emory Healthcare Veterans Program. We are able to see post 9/11 Veterans from all over the country. Everything is at no cost to the Veteran. We fly them into Atlanta. We put them up in a hotel for two weeks. We feed them. We give them more therapy in two weeks than most people get in a year. We treat them every single day for two weeks with individual exposure therapy, group exposure therapy, family therapy, yoga, medication management. We've got a sleep Doc that works with us in a Sleep Lab in our building. So, I think you have the information that you can put out there. It's really a win-win-win for everybody. And unfortunately, we're one of the best kept secrets, which we don't want to be. So, if you can help us get the word out, that'd be terrific.
Kim Bullock
Yes, let's not keep that a secret. Thank you.
Jessica Hagen
Yeah, that sounds very, very promising.
Barbara Rothbaum
People can follow us on Facebook and Twitter at Emory Veterans Program @EmoryVeterans, can visit our website, emoryhealthcare.org/veterans. Or call us at 888-514-5345. That's 888-514-5345, emoryhealthcare.org/veterans.
Kim Bullock
Thank you so much! We appreciate all you do, again, for providers, patients, trainees and the public and for advancing the use of XR, especially in PTSD. And we very much appreciate you coming.
Barbara Rothbaum
It was my pleasure. It's very fun. Thanks for having me. And thanks for helping me get the word out.
Kim Bullock
So that's it for this episode of Psychiatry XR. We hope you gained a new perspective on using extended reality in health care. And thank you so much for listening! And this episode was brought to you by Psychiatry XR, the psychiatry podcast about immersive technology in 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.