Brandon Birckhead: Path to Psychiatry and Exploring the Challenges of XR
The following is a transcipt of the episode:
Faaizah Arshad
Hello and welcome back to Psychiatry XR. We aim to inspire worldwide conversations around the use of extended reality in psychiatric care. I'm your host for this episode Faaizah Arshad, and I'm joined by my amazing co-founders, Kim Bullock and Jessica Hagen.
Kim Bullock
Hi Faaizah.
Jessica Hagen
Hi Faaizah.
Faaizah Arshad
Hi, Jessica and Kim. So the three of us created Psychiatry XR, which is a monthly podcast for all XR and behavioral health stakeholders and many more. And today we're very delighted to welcome Dr. Brandon Birckhead. Dr. Birckhead is a physician who has been working on virtual reality clinical research since 2016. He has spent three years as a scientist at Cedars Sinai and Dr. Brennan Spiegel's lab, where he helped design large randomized clinical trials, exploring the use of at home self-administered VR therapy for chronic pain. He was also the Co-director of the Virtual Medicine Conference during that time. He's hosted a podcast called Immersive Psychiatry, a series focused on immersive technology within mental health. And he received his medical degree from the Mayo Clinic and is currently a psychiatry resident at Johns Hopkins. Thank you so much for joining us, Brandon.
Brandon Birckhead
Absolute pleasure. Great to meet all three of you.
Faaizah Arshad
Thanks, Brandon. So as an undergrad student, myself, who's studying psychology, I have been interested in the mind and behavior for a while now. And I've just now started realizing how extended reality can be important in this field. But I'm very curious to know how you first got involved in psychiatry, and if you always saw yourself pursuing this path? Maybe like, what the trajectory was like, and why you chose this specialty over others?
Brandon Birckhead
Great question! I would say, for me, technology has been somewhat of a deciding factor for a lot of what I went into or started going towards within healthcare. Initially, that was something I knew I wanted to help patients, and then work with technology, and so I actually initially did research and went into a matched radiation oncology— because the field is actually defined by the fact that it is working with technology, but also helping patients. Soon after matching, as you will someday see, you actually have free time after the match, which is an amazing thing after several years of work. And so I took my free time to just explore hobbies of interests, and one of them was whatever is the new technology. So I found meetup groups. One of them was on virtual reality. And so it was just an outside group of independent developers, really just enthusiast mostly, and tried VR for the first time that night. And like many people in the field, I was terrified. My sense of immersion was enhanced by a feeling of being terrified, some by falling or feeling like they could fall off of the building, mine was a T-Rex coming at me from down a hall. And it was just how real it felt, you know, I won't lie, I kind of went into almost like a fetal position as this T-Rex like just starts to eat at me. And that thought was, if it could cause this type of emotional response, that there must be positive implications for what the sense of presence was. And so that night, I went home and I started just reading papers searching for virtual reality, and that was in beginning of 2016. And so, I just started looking and was surprised by what I found. Essentially, for those first two years residency, I was just working at night on VR research, mostly what I could do when you don't have money, acute pain with a bucket of ice (what they called ‘cold pressor tests’) can be done on a low budget. And I initially did that with medical students and residents testing their tolerance for pain, and just kind of replicating studies that I found. And it was empowering because research as a student is daunting. It's daunting at any age. But knowing I could do something without funding was a relieving thing for me. But it also enhanced the fact that I felt that I was living two lives: one for my research, which felt like it was focused on the mind, and then my day job, which was focused on oncology and treating cancer patients. Radiation is a wonderful treatment for patients that need it. But I did not feel like I was going to split the atom again, or figure out something new for that area. But, it felt like there was a wild west of what to do with an immersive computer. And so it was strong enough that I actually made the decision that most would not recommend, which is to leave residency, and to take on a full research position without full knowledge of what that would mean for someone without a PhD and maybe solely an MD. But I did it and don't regret it. It was a great decision for my life: helped really solidify some of my skills and perspectives (on research and on the technology), getting to know everyone in the field, getting to meet Kim at her conference that she did soon after that. I feel like it was about a year after I'd gotten into it that you had the conference, I think in 2017. I began to think of psychiatry actually at the conference that Dr. Kim Bullock did facilitate. And so I've met many psychiatrists, and it felt like of all the specialties, that is where you could really get into some of the most complex interventions. It's also the language. The language of the mind is very important for both diagnostically understanding the patient, and the things that they're faced with, but also how they could relate to this technology. And so it took me a little bit to really solidify that I felt like I still had the energy to go back and do this! I did. And I was like, “I can do this one more time.” The reason why they say, “Do not leave a residency,” is that there was a bit of a scarlet letter on me for when I applied. I applied to like 64 programs. And I think six gave me an interview. Thankfully, one gave me an offer. It was outside of the traditional match, so this is allowed. It was a non-traditional spot. And so, I said, “Absolutely!” I don't know if they knew what my chances were out there beforehand. So I was very glad when Hopkins gave me the chance. And it's been very confirming, very validating to be in the field to work with patients, to learn about therapy and to see the depths of mental illness. Yeah, and then just start the podcast, which helped me to start studying for the field as well.
Faaizah Arshad
Yeah, I think all of that just sounds so inspiration and it almost seems like it was meant to happen. And I'm sure the psychiatry field is just so lucky to have you. But you started off talking about what got you interested in virtual reality that one night when you were, you know, playing with a VR device, and you thought it's just so realistic. Can you elaborate a little bit more on why else you feel like XR in medicine is so appealing, and like interesting to you as a resident?
Brandon Birckhead
Yeah, things that are appealing about immersive technology. So technology overall, most of it is run off of like a computer of some kind. And we all integrate with computers to a significant degree of our day, the smartphone being the thing we're most integrated in. So there's a lot of interesting things that can be done with a phone, I think, a lot of reasons we should be using phone-based things for digital interventions that are sometimes even better, at least for what we have currently for immersive technology. There are limits to this novel, high-end computer. But if I was to say, what are the key things for the device: part of it's definitely that immersion. So what I was talking about was, you know, immersion is whatever hardware properties, software properties that cause you to feel a sense of presence, and presence is feeling present in a virtual or around some virtual entity, whether it's your entire surrounding space, or just something in your day-to-day life. I don't know if that's helpful. What's helpful for me is to think of high-def TVs. Back in the day, something was given the label with high-def TV, which was like a certain amount of pixels. But it meant for the customer, when they show these advertisements was, “Oh, I can see sweat on the football players head.” Why is that even of use? You know, do they want to just chase that pixel count? Maybe. But I think it's also because they feel like they're present with that football game without having to be at the football game. And so I think that the jump that someone gets when they're at Sunday football, that's the sense of presence, that's a feeling. And then the high-def TV is immersion, and there's requirements for that for VR, or mixed reality, whatever device. So there is something key there for perspective shifting, perspective change, feeling an emotion. Maybe another thing, if we want to get technical, there's more data that you can garner from this device. So there's some interesting back-end related things. But outside of the garnering of more data, and presence, there's a lot we can get your smartphone, but those are the two things that seem compelling.
Faaizah Arshad
Got it. Yeah. The feeling of presence and then the data that you can gather. And you also talked a little bit about, you know, the conference that you were at and how you spent some time at Cedars Sinai. Were there particular studies or projects or controlled trials that you were involved in that sparked this interest into therapeutic technologies for patient care?
Brandon Birckhead
Yeah, I would say that even before that, that I learned a lot from things that were so challenging or that I didn't do well enough that they couldn't be published, but they were learning experiences. So I think that my very first thing was literally buckets of ice that I would assess the temperature for, and this is when I was an intern— so about two years before I went to LA— and getting to see that there were certain programs that did better versus others that confirmed kind of what was in the literature about having a moderate amount of cognitive load, distraction-based things, distracting enough, but not too difficult. So I found that to be fun and enjoyable because I could do something and I felt the need to know that I could. And then I worked with some collaborators who actually had some money at Mayo, and they went and did the actual study. And that was good. They got published, which I'm thankful for. I think the next thing would be when I was at Cedars, most of my time there was trying to get a study that actually, we couldn't get it published, but it was our first attempt at doing at home VR. And that was, you know, understandably challenging. But mostly it was the challenge was trying to go from doing VR in the hospital and recruiting people in an appointment, versus recruiting people who might do this at home. There's a challenge and pressure with trying to recruit in an appointment that can be very short, or for people that have very little time. And so we had to make modifications. So it was a good learning experience to see what needs to be done or what kind of inclusion / exclusion do you need to have to facilitate at-home VR, and in subsequent grants that Dr. Spiegel has, will succeed where that initial study more so was a learning ground.
Faaizah Arshad
Right.
Jessica Hagen
And how did your time when you were at Cedars Sinai inform your current work? How does your current work in psychiatry really involve virtual reality?
Brandon Birckhead
It doesn't involve it much. I would say that I have gotten a few patients interested in using it. So my first year of psychiatry was all inpatient. And I definitely think that what I have learned is there are many times where I'm probably not going to use VR because of the intensity of the experience. Anytime where you feel like maybe psychotherapy is not going to be a good thing right now, in this moment, is probably challenging to use VR. Now I say that, but I do think there are many things like distraction, relaxation, deep breathing, meditation, those could be implemented in the inpatient unit. And probably if I had staff, or if I had more time than what I have as a resident, I would have experimented with that more. It would be a great inpatient study. There are a few good inpatient psychiatry hospital studies that have been done. So I do think you could use it. What I've used it is I’ve had a few patients that were more socially withdrawn after having severe depression. And they were young. You know, they might already have a headset. Really, they kind of had to have a headset. I definitely don't have the funds to give them headsets. And there's not a prescription code for that, but, but they had them. And so I would show them some things that I thought were useful. Particularly what I found useful is one of our colleagues, Kim and I have, is Noah Robinson at Vanderbilt. And he has a support group program called Innerworld, and I would show them Innerworld, which then they can just go on their own and be able to meet with people and be able to socialize, even if they feel a bit difficult in doing that. Particularly if they have social anxiety with individuals, I found that there is some utility in them feeling a little bit of a less of a barrier to interact with others. So I've done that. And I've had lots of discussions with faculty about possible research studies. I think that it hasn't come off the ground because I think it's, you also are kind of like getting them more comfortable with what VR and AR is. And we don't have a great example of that within the department yet. But it is something that I've worked to hopefully get more interested in and then work maybe with the undergrad, with the Engineering Department to think about making something in-house, which would be exciting.
Kim Bullock
Yeah, Brandon, I really remember you so fondly at the conference and your enthusiasm and, and it made the conference worthwhile just to kind of see your face and see how excited you were. And here you are doing so many tremendous things now. And I know you were very thoughtful in your decision to go into psychiatry. And then I'm wondering, is there anything now a year into psychiatry residency that you weren't expecting or things that you're noticing or barriers or something that just was not on your radar? Or is it pretty much what you expected?
Brandon Birckhead
Yeah, I definitely think that a lot of it's what I expected. I definitely think there are barriers to getting mental health treatment that I was unaware of. And there are complexities to the system, there are patients that have very low resources but significant mental health burden. There's not currently a place in our healthcare system or actually in our society that really supports these individuals well. That is a real shame. So, I think I've seen more of the complexity, and it is difficult the barriers we have and that our patients have. But otherwise, it has been, as I would expect, enlightening, to see how hopeful there is for so many different treatments. And we really need treatments, some of them ultimately to possibly even try to cure, if possible, to have a remission that is permanent, or has permanence. And I think that there's things that look quite interesting and compelling. And I hope in my lifetime that we get to see more things that could cause permanent remission. So that's exciting.
Kim Bullock
Oh that’s really great. And so, do you think that informs any of your ideas or thoughts about innovations to address any of these barriers? Do you think you've modified your focus or will because of your deeper understanding of the mental health system?
Brandon Birckhead
Yeah. It feels like a lot of it is, if I was more policy person, I think there are huge policy campaigns where I think there are some things that were done potentially well, even in the 50s and 60s that we have discontinued at times, like support for people long-term for mental illness. And then I think that how it has informed my thoughts on VR research, I would say that I feel more confident that there's a spectrum of implementation for the technology. I think that looking at like an academic center looks— for you, I’d be very curious your thoughts on this— but it feels like the virtual reality clinics that are formed (first one to my knowledge at least in the US was your clinic), but I think that high intensity VR is a really interesting area where it could be used for those at the sickest, most severe or more severe level with guidance from a therapist or psychiatrist. And you can use it with other modalities like neuromodulation and in different clinical care settings. And that's kind of the one end of the spectrum. And there's this other end of the spectrum that I think most of the industry, if we were to go to like virtual medicine, and then you were to go to the exhibitor booths, those are marketing for the more higher, more severe end of the condition spectrum. But I think there is a spectrum, where the studies I was working on were for self-administered at home, you know, you could use it for homework between therapy sessions, but really, I think a lot of them are using it for kind of the group that's either subclinical, subthreshold, or have not, have maybe, are diagnoseable, but they haven't come to the system yet. They're just out there white knuckling whatever is going on. Right. And so I think for digital health more broadly, even outside of VR, just kind of anything that’s on an app, there is this kind of, if there was such a thing as a step care model, for mental health or for health overall, there would be this thing you could get, even if you just reach out to the world, reach out to the ether of the internet, something would come out of it. And you would have this thing, right. But that thing by itself if you have severe illness, maybe not going to fix it, but it's part of that spectrum. And then you might end up in the VR clinic or some clinical setting and be used differently, I guess.
Kim Bullock
Yeah, you're really seeing these different levels of care, and different ways it can be integrated into different levels. It sounds like you’re thinking about that. One last question I had too was since you have been involved in such a multidisciplinary way in the science with commercial startups and industry and residency in academia, do you see any conflicts of interests that could create problems for us in innovating XR to psychiatry, or any personally for yourself, and how you would recommend managing those to people in the field?
Brandon Birckhead
Yeah, definitely. I think that we should take a look at what has happened with pharmaceutical industries. I think that there are positives that have come out of it. But yet we have seen some of the negatives. And we figured out there's this church and state kind of separation that's useful in the sense that if we compare research that was done thus far, for things that are run on a pill, it's quite immense the amount of research that was funded for a pharmaceutical pill. And that's because the industry can garner a fair amount of capital. So we can't deny the fact that in comparison to like a TENS unit, or even therapy for most forms of even medical devices that aren’t kind of higher end, not surgical things that will garner quite a bit but, maybe things that would be not so high ticketed items, therapy or lower tech things just don't have the same number of, or same size I would say, clinical trials. And that is in part, through different research mechanisms that indirectly or directly were funded through pharma. So there's that utility. There's also probably utility from the fact that probably our CME courses and some education, I mean, it definitely was historically funded by pharma. Now, there has to be a separation there. But, but there's so much need for education that that actually some payment there is good because otherwise we've also seen a lack of funding for educating providers and the public. So I think there was positives there. Now, there's also, there's conflicts of interest when you mix those between the two. So I think that when I do start to run my own studies, and in general in the IRBs and whatnot, you would have conflict of interests that you would go through. And I think that with academia, and any IRB, that's probably a worthwhile IRB, there's worthwhile ones that are external IRBs, you can go through the COI process, and then you can declare it. My thing is long as it's declared: two things. One is, it lets the public know what to think of when they're assessing what's being said to the public or providers and patients. Two, then you can also help define mitigation strategies. And so I think that knowing that there's providers that have lots of different interactions with pharma, that it’s going to happen because they probably helped to perform these treatments. Some of these things are their life's work for research. So I think that it can be unavoidable and there can be some benefit to synergy. But I would definitely say that the conflict of interest office is a good place to work with.
Faaizah Arshad
How do you think that clinicians should work with industry people to improve the value of XR in patient care? So I loved how before you talked about how you recognize that there's like a spectrum of patients and diagnoses and how maybe we need to have a step model. But in general, because this is so interdisciplinary, what's a good way for psychiatrists to be working with people in industry and in academia and in business, to improve patient care in XR?
Brandon Birckhead
I would love— I mean, I think if they have the time, it's always a challenge of time— I think people that have the least amount of time is the full time clinician because they probably were packed and busy 10 minutes ago, you know, or they're booked to the end of the day, whether they added anything else to it or not. So I think that it is challenging to get their input. But when they can give their input, it's invaluable because of that exact problem that they have almost no time, the demands can be high, or the product doesn't fit their needs. And so I think that their input is invaluable as providers. I think that if they can interact with most startups, it'll help improve the product. If they can interact with the academics, they can figure out what questions are really important to them. An academic could probably spend their whole life on maybe what might end up being a semi esoteric question. And if they hear from enough providers, “It's got to be cost effective” or “It's got to work on this implementation site,” well then may be some of them will be like, “You know what, I'm going to do an implementation study” or “I’ll do a cost effect study.” Then maybe they don't love it. Or maybe they just didn't think that would be as important as whatever question they wanted to ask. But they may be able to change. They adapt. Yeah, I think everyone should try to talk because every perspective has a slightly different interest and/or goal. And it's very easy for, say, academia, and startups to have different levels of goals, and/or there can be some bias in both perspectives. And then many times these interactions just end. So this year, I spent time working with the Center, we were thinking about a Center for Innovation within the psychiatry department. We wanted to build this to help support startups. I interviewed several startups about the challenge of trying to work with academia, and then I interviewed some heads of academia about the challenge. And it's definitely a lack of transparency on both parts that needs to be kind of there to make it work. As far as if there will be a Center for Innovation, we're still kind of, it's an early thought process. But it was enlightening to see that there needs to be more attempts at successful interactions.
Jessica Hagen
You were very entrenched in this group at Cedars Sinai that was pretty supportive of XR in medicine. And when you moved over to Johns Hopkins, what's been the response from your peers there in the psychiatry department to virtual reality use in psychiatric care?
Brandon Birckhead
Yeah, understandably, I think many initially are skeptic. It's totally understandable that they are skeptic. I think that they have an idea of what therapy should be. So a key example with any technology in health is when they want to do therapy face-to-face and then you bring out social VR, let's say it's VR chat, which was and is still semi popular social VR program. And it was, it's always interesting that they go, “I can't tell if they're smiling or frowning with this.” And I'm like, “That's true. Most headsets do not have face tracking.” And they're like, “Why, why would I do this, instead of Zoom?” And I go, “You're making valid points right now.” Ans so right now, there is maybe a semi unique niche for social VR in the context of a billable —maybe not a unique niche, it can expand on this. But for exposures, you can create an exposure in the world that has high utility for patients who could benefit from an exposure. Otherwise, there are things you could do, but probably what it's helpful for is there's some again, it's some individuals that might be so socially anxious that they are, “I don't know, if I want to show my face on the Zoom.” So now, I know there's a startup that's working with pediatrics and pediatrics have higher rates of social anxiety, kind of happens during that time period, at least starts in that time period often. There's also somewhat of a playfulness that is enjoyed. Play therapy can be done. And that's something that makes sense again in VR. I think as the technology improves, it will gain more utility, and right now, is probably one of the first devices that has, for consumer level use, has face and eye tracking. And that means it's pretty early still before that probably grows to the point where I think it could be a clinical utility. But we'll see.
Jessica Hagen
It's quite fascinating because it seems like when I met you years ago, you were very, very excited and entrenched in the use of XR. And now it seems like you do have kind of a skeptics mind a bit about it.
Brandon Birckhead
I think it depends on what it's for. I think because when with therapists, mainly when they think of therapy, it's face-to-face. There's a couple issues there with face-to-face therapy. This goes without saying it's, I'm equivalent to AGI ,an artificial intelligence of general intelligence, which is just human level intelligence. You know, I can switch topics, I can have people imagine, you know, you can help patients imagine whatever their challenges are. And that is really hard to do in VR still, to a degree. And so when it comes to self-administered, so when we met each other in the conference, self-administered, you know, the apps that are out there, for smartphones, most of them are text based apps, which is great. You could probably turn every workbook in psychotherapy into an app right now. And probably many of them have an app. They usually end in the word ‘coach.’ And they're pretty good. I use CBT-i Coach. I use ACT Coach. I use it with many of my patients, and I enjoy getting the feedback on their mood tracking. But, that's not very compelling. So I think that I am still very much excited for the use of immersive technology as like a higher potency version of what we can do on a smartphone, which is just text. So I think I'm very high on that, as far as excitement for that. And then yeah, I think as I learn more about face-to-face therapy, there's definitely utility for it. And there's definite cases. Right, Kim?
Kim Bullock
Yeah.
Brandon Birckhead
I mean you could give some examples for the clinic.
Kim Bullock
I'll say, yeah, I don't see it as a replacement for human psychotherapy, but more of an enhancement is the way I'm viewing it now. So I don't think it can replace imaginal exposures very well. Our own imagination is so much better, that it's not really great for substitution for imaginal exposure. It's very good substitution for in vivo exposures— things you have to go out in the world, like you might be avoiding going to the grocery store, queues or things that you need to do and you can practice them before you go and you can desensitize and habituate in a privacy of your own home and with your therapist guidance. And then the other thing I think is really cool is the skills because a lot of psychotherapy, if you're doing more cognitive behavior therapy or some of the evidence-based psychotherapy, is there's protocols. So it's really your teaching patients skills. And they don't like to hear me drone on and on and give a little lecture to each patient. So I can give them you know, in the session, say, “Have this VR experience. They're going to teach it to you in a much more engaging way that you're going to remember more.” I won't have forgotten anything. It's more the fidelity of the treatment I'm giving is going to be enhanced. And it reduces the burden on me. I can get my note done or I can pay attention to something else. Because burnout for providers is a big thing too. So I could maybe see more patients that day because I've farmed out my teaching for a few minutes for each patient. So I kind of see those. It's more of like an enhancement or increase the efficiency of psychotherapy, or maybe can scale it. Just, just a bit. But I think at this point, that's, that's what's here. But it'll be a while before it's a real replacement, just like the digital apps have the same issue. You need a navigator. Yeah.
Brandon Birckhead
Even doing further enhancement. Once I finish residency, I may go back the podcast. The last episode was on what it would take for it to be useful in any therapeutic encounter. And I think this is where you would need some infusion of artificial intelligence because patients will literally come up, in a single appointment could come up with three or four things you did not know were an issue. And so if you can't, you'd have to almost come up with 3D objects on the fly, which is not possible. And so, you know, I definitely think that over time, probably the game engines will likely add in some kind of semi artificially intelligent thing that could kind of tag objects, bring them in, and then you could have this like, interaction that could be used kind of for anything. Then it's just a great tool box for anything. I agree with you 100%, that it is exciting tool box, that will likely grow over time with its benefits. Yeah.
Kim Bullock
Yeah.
Faaizah Arshad
Do you want to elaborate maybe a little bit on how you hope it'll grow in, say, like 20 years? And what do you think are some challenges that we need to solve to get there?
Brandon Birckhead
Lots of things, I think that in the short term, it's probably still a thing of comfort. There are some populations with VR side effects where you can have maybe up to 20% of the population will have, there's a barrier of side effects kind of limiting the amount of time you can spend in XR, maybe in total, but still a lot of benefits. So I would say that in 20 years, the only thing I really put money down on is that I think VR will still be of use. Full immersion is still useful when you need to escape your environment. So I think some people are at a level of arousal due to their current situation that they would like to escape it. So I think in 20 years, we would still have VR, but it will be a smaller proportion of the total use of immersive technology. I think that probably by that time, we would have glasses. Yeah, AR glasses. And it's hard, because so, you know, right now I'm wearing glasses, but imagining what is equivalent to what is on a cell phone in this thing is pretty hard to imagine. But 20 years is a really long time. There's a ton of money going into that. So I think once you have it at that level, then you're talking about the use of this for day-to-day life. And if you're talking about the use of immersive technology for day-to-day life, it opens up its utility. It's not just for— you know, by that time, we'll get good at cognitive restructuring, and more difficult CBT tasks as well, you know, we won't just be for exposure based therapy. But you could also use it for behavioral for day-to-day behavioral changes, for kind of in your life changes, not just this intensive,” I'm going to use this for a designated period of time.” So there's more utility for it across the day when the phone goes away entirely. I guess. Yeah.
Faaizah Arshad
You sort of see it as being more of a routine and regular utilization of, of just XR devices instead of just for like intensive, you know, therapeutics and just for health care.
Brandon Birckhead
Yeah, I would think so.
Jessica Hagen
I wonder if that would kind of bring about its own challenges, though, where people would, you know, social media was, was put on the cell phone. You know, you could access social media, and that can cause different behavioral issues, you know, with a lot of people, and I wonder if there's something that could come of wearing augmented reality glasses, mixed reality glasses on a daily basis that could trigger some type of other psychiatric disorder that we are not even privy to at this point.
Brandon Birckhead
Yes, I'm both excited and concerned in the sense that, so some examples of use of this is that social media has been used to manipulate consumers or individual people, or it has been used by groups that have their own intentions at heart, which may not be good for the individual. So one of them that I've seen with my patients when I was on the eating disorder service is social media groups that are pro anorexia, pro bulimia and seeing patients spend hours, like hours and hours and hours of the day engaging in these groups that would try to help reinforce behaviors and habits that are not helpful for the individual. And I think that in an immersive world, there are studies right now being done to help people with those actually same behaviors in VR. But I imagine bad actors could try to use it in the opposite way. I guess what I say is, I don't want to be naive to think that you could only use this for a positive effect. One good example would be— this is a hypothesis I have is— that virtual embodiment is something I'm very excited about. So it's a very, when I say virtual embodiment, it's a very specific thing. It requires full body tracking in a virtual avatar and a mirror. Usually, you need some reflective surface for you to really feel like when you move, this virtual avatar moves. And for seconds, milliseconds at a time, my brain does not is not able to think of two different entities. It has only evolutionarily been created for one body. So there's some utility in having an emotion that you can garner from a virtual body’s experience. One of them that I found very powerful when I went to Barcelona with Dr. Spiegel was an out of body experience. An out of body experience seems to have a sense of feeling of connectedness afterwards. It's overall a positive experience, sometimes an awe inspiring experience. Now positive awe-inspiring experiences are usually good, and usually positive things that we might use for people who are terminally ill, or maybe even potentially depressed. However, there is one population where you would have caution. And I think we would have caution for people that are already suffering from dissociative disorders. So people who might be— let's say, I have a patient, and they're severely depressed, essentially contemplating suicide, and having dissociative, out of body experiences. My only concern, what I would need to assess there's a few papers trying to assess suicidal thoughts, which is important for us to explore in a safe way. And so there are researchers looking at the ethics as well as the utility of this technology to assess for that. But you can do that in a study, which will be very important. And psychiatrists should be looking into this because it's literally the worst outcome that we're looking at. But my only concern is if there was a future someday TikTok, and there is some pro depression group, and they want to disassociate with each other and, you know, act out certain things. I think that is not good for society. You don't have to do anything too preemptively. I think we're, we're conscientious of it at this time that I'd like to think, maybe I'm an optimist, but I like to think that we will be able to study this, hopefully quickly. But yeah, I think we can try to assess this. And hopefully this time around, we will make adjustments that maybe didn't happen with the last generation of computers.
Kim Bullock
Yeah, I think you're very wise about that, that autonomic dysregulation that goes along with emotional dysregulation, and is correlated with heart rate variability. Those people seem to be more able to have embodied experiences more quickly. And they also suffer from dissociation. So we don't want to make some behavior that they do worse. And yeah, and so we do need to be studying this and be aware of the things that we don't know. Yeah. That was very wise to bring up.
Faaizah Arshad
I think that's where sometimes having skeptics can be helpful. Just having people questioning the way that we're using the technology and ways that it can be improved. Because if people aren't raising those questions, then like you said, Brandon, how are we going to be making adjustments to the way that we're treating our patients?
Brandon Birckhead
Yeah, yeah, and just to say I would say the only disclaimer I would say is currently, consumer based technology really can't do full embodiment. So I guess if someone was listening to this, and they thought, “Oh, no, this could happen right now out in the space.” To my knowledge, I've actually helped a colleague on a study, this is back with the Oculus Go (she's now redoing it at Cornell for the Quest), and to our knowledge, we really can't reproduce full body tracking like you can with the more expensive equipment. That's really, it's a hypothesis that I know will likely be explored further.
Kim Bullock
Yeah, needs to be explored.
Brandon Birckhead
Yep.
Kim Bullock
Yeah. Well, C2Care is having embodied exposure experiences.
Brandon Birckhead
Who does that?
Kim Bullock
Bouchard from Canada.
Brandon Birckhead
Oh, yeah, yeah, yeah!
Kim Bullock
And they have a commercial. So, we need to be careful. Our compliance department’s still looking into it, but there are risks and so we need to be aware of them. Make patients aware of that. So there are fully embodied commercially available things for clinicians to deliver to patients, but it should be, it should be clinician guided. But I guess you can get into an HTC Vive if somebody spends enough money, or Oculus Rift and has a embodied experience. I guess that they can access it. But just be careful, everyone.
Brandon Birckhead
Yes. Be careful.
Jessica Hagen
Yeah, be careful.
Faaizah Arshad
This has been so insightful, Brandon. And I think I just love to come full circle and ask you, so you're still early in your trajectory with psychiatry and you know, hopefully going to be making a lot of great insights and moving this field forward. But for someone like me who's just starting, and for other listeners who are young, and who want to get into psychiatry and extended reality, what kind of advice would you share? Like, what things did you maybe wish to know when you were just starting? Or that you've now realized, and you know, kind of in hindsight and thinking back at your journey, just what tips and advice would you have, for younger folks who are also just starting their trajectory into this field?
Brandon Birckhead
I would say, mostly to follow the passion. And I would say that, in particular, though, find out whatever you might be naturally good at, or something that you really enjoy to do within the field. There's many different skill sets that could benefit you. And I think that for some people, it's the technical side of things, kind of the coding side. And I think that if someone was going into psychiatry, they should learn as much as they can about the field because they likely enjoy it. Get involved as much as they can, just as you have with this podcast. I think that’s a great way to learn and to get involved. I think that some will, will code and that's a very interesting thing. I've met psychiatrists that are developers as well. Wonderful way to get involved. But that's it for certain types of people, certain types of psychiatrists, really people in general. Others, I think, enjoy research like myself, and will get involved in research, and that be how they want to contribute. Others, I think are more of the policy, maybe they were a psychiatrist that in a different life could have been a great politician or just a great leader, and they love understanding the structure. And so I think there's definitely leadership roles, if they work up making this their area of interest within the field. So I think, just do whatever is something that you are wanting to do, put a lot of work into for a long period of time, but just enjoy it. And there is room for you, for whoever that has that type of passion to move forward.
Faaizah Arshad.
Great. And is there any final thoughts that you'd want to leave our listeners with?
Brandon Birckhead
Definitely looking forward to the future. I think there's more and more that will come for the field. And I hope everyone is excited. And I'm also excited for what you all are doing with this podcast, but also, Kim what you're doing Stanford, and it's all exciting to see how things evolve over time!
Faaizah Arshad
Yeah, thank you so much for taking the time.
Jessica Hagen
Thank you so much for joining us.
Brandon Birckhead
Yeah. My pleasure. Thank you. Thank you all.
Faaizah Arshad
That's it for this episode of Psychiatry XR. We hope you gained a new perspective on the use of extended reality in healthcare. And thank you very much for listening! We're also very grateful for the support of the International Virtual Reality Healthcare Association, who is offering you our listeners 50% off when you register for the 7th annual Virtual Reality and Healthcare Global Symposium taking place on March 3rd – 5th at Penn Medicine in Philadelphia. To learn more about the conference and to register to attend, visit health23.ivrha.org and use the discount code psychiatryxr when registering to receive 50% off. This episode was brought to you by Psychiatry XR, the psychiatry podcast about immersive technology and mental health. For more information about Psychiatry XR, visit our website at psychiatryxr.com. Be sure to subscribe to the podcast and tune in again next month to hear from another guest about XR’s use in psychiatric care. You can join us monthly on Apple Podcasts, Twitter, Spotify, or wherever you get your podcast. Psychiatry XR was produced by Dr. Kim Bullock, Faaizah Arshad, and Jessica Hagen. Please note that this podcast is distinct from Dr. Bullock's clinical, teaching, and research roles at Stanford University. The information provided is not medical advice and should not be considered or taken as a replacement for medical advice. We credit and are very grateful to David Bell for audio editing and Austin Hagen for music production. See you next time.
Kim Bullock, Jessica Hagen, and Faaizah Arshad chat with Brandon Birckhead, psychiatry resident physician at Johns Hopkins Medicine, about his trajectory into psychiatry, interdisciplinary collaboration among XR stakeholders, and his hope for overcoming the challenges of XR implementation in medicine to improve patient care.
BIO
Dr. Brandon Birckhead MD MHDS is a physician who has been working on virtual reality clinical research since 2016. He then spent 3 years as scientist at Cedars-Sinai in Dr. Brennan Spiegel lab where he helped design large randomized clinical trials exploring the use of at-home self-administered VR therapy for chronic pain. He was also the Co-Director of the Virtual Medicine conference during that time. He also hosted a podcast called immersive psychiatry. The first podcast series focused on immersive technology within mental health. He received his medical degree from Mayo Clinic and is currently a psychiatry resident at Johns Hopkins.