Brenda Wiederhold: International use of XR

Kim Bullock M.D. speaks with clinical psychologist Dr. Brenda Wiederhold on the international and interdisciplinary impacts of virtual reality for psychiatric and behavioral health, including ways to advance collaboration between psychologists and psychiatrists, promote diversity and inclusion, and manage conflicts of interest with industry and science.

BIO

Brenda K. Wiederhold, Ph.D., MBA, BCB, BCN is Co-Founder of  the Virtual Reality Medical Center, a California Medical Corporation and the Interactive Media Institute, a 501c3 non-profit.  She is a Licensed Clinical Psychologist in the U.S. and Europe, board-certified in Biofeedback and Neurofeedback, and a Visiting Professor at the Catholic University in Milan. Her Ph.D is in Clinical Health Psychology, and she is on the medical staff at Scripps Memorial Hospital, La Jolla and a member of the Pain and Palliative Care Committee.  She’s Editor-in-Chief of CyberPsychology, Behavior & Social Networking Journal, published by Mary Ann Liebert, Inc. Publishers. She’s organized the CyberPsychology, CyberTherapy & Social Networking Conference for 25 years.

The following is a transcript:

Kim Bullock:

Hi there and welcome back to Psychiatry XR, where we're on a mission to inspire worldwide conversations and innovation around the use of extended reality and psychiatric care. I'm your host, Kim Bullock, and I'm a clinical professor and XR researcher in Stanford School of Medicine. I'm board certified in psychiatry, behavioral neurology and neuropsychiatry as well as lifestyle medicine. Thanks for joining me on this journey as we are discovering together how XR technology is influencing the field of psychiatry and mental and behavioral health care. Please note that this podcast is distinct from my own clinical teaching and research roles. And the information provided is not medical advice and should not be considered or taken as replacement for medical advice. I'm so excited to be joined today by a pioneer and leader in the field of clinical psychology and XR for mental health, Dr. Brenda Wiederhold. I am such a fan of hers. Dr. Wiederhold is a co-founder of the Virtual Reality Medical Center, a California medical corporation, and the Interactive Media Institute, a 501(c)(3) nonprofit. She's a licensed clinical psychologist in both the US and Europe, board certified in Biofeedback and Neurofeedback, and a visiting professor at the Catholic University in Milan. Her PhD is in clinical health psychology and she is on the medical staff at Scripps Memorial Hospital in La Jolla, and a member of the Pain and Palliative Care Committee. She's editor in chief of CyberPsychology, Behavior, and Social Networking journal published by Mary Ann Liebert Incorporated Publishers and has organized the conference for the past 25 years as well as founded it. Dr. Wiederhold’s Virtual Reality Medical Center (VRMC) has offices in Sorrento Valley, La Jolla, Coronado, California, China and Belgium. And Professor Wiederhold is registered as a licensed clinical psychologist with the California Board of Psychology, the Belgian Commission of Psychology and the Arizona, Nevada, New Jersey, and Virginia Boards of Psychology and currently maintains a private practice. She is an advisory board member for The International Child Art Foundation in Washington, DC as well. And she is a rare mental health provider who has actually been successful in straddling both excellent clinical care and clinical research. She has over 300 scientific publications and is currently completing her 18th book. She is recognized as the international leader in the treatment of stress related disorders, anxiety, panic, post traumatic stress disorder and phobias, burnout and pain with virtual reality exposure, biofeedback and cognitive behavior therapy. In 1996, she conducted the first randomized control trial using VR and biosensors to treat fear of flying. In 2006, she conducted the first randomized control trial using VR to treat Iraq and Afghanistan war veterans suffering from PTSD. She's conducted over 10,000 VR therapy sessions, and given invited lectures and training programs in 29 countries throughout Europe, North America, Asia, and the Middle East. Professor Wiederhold works to inform and educate policymakers, funding agencies, world leaders and scientific community and the general public about the transformational impact of technology and how it can affect health care. As a US citizen, Dr. Wiederhold has lived and worked in Asia, Switzerland, Austria, and Belgium giving her a unique world perspective on this subject. And we're so honored to have her with us to give her unique international perspective. And thank you, Dr. Wiederhold, it is such an honor to have you join us! 

Brenda Wiederhold:

Thank you, Dr. Bullock. I'm really honored and appreciative that you gave me this opportunity. 

Kim Bullock:

Well, great. I thought we could just start off by maybe having you tell us a little bit about yourself. Maybe how you first dove into clinical health psychology and then how that kind of morphed into extended reality work, and why did you start to use that for your psychological care?

Brenda Wiederhold:

Sure, absolutely. My first career was actually in finance. I had my MBA, but I'd always wanted to be a psychologist. And when I came back to psychology, I did my research first as any good financial person would do. And I found that I really was drawn to the intersection of medicine and psychology, so getting the clinical health psychology degree was a no brainer for me. It allowed me to have the objective metrics as well as ask the patients how they felt. And I went to one of the first Medicine Meets Virtual Reality meetings in San Diego over 25 years ago. And I heard Jaron Lanier talking, who's the person that really coined the term virtual reality. And then after him, a scientist from Milan, Luigi Pugnetti, who's unfortunately passed on now, but he was speaking about putting a patient into a virtual world, measuring their physiology, and helping to use that to guide therapy. I thought, oh my god, this is brilliant. I was already seeing patients, taking them on freeways, on airplanes, into elevators, and treating their phobias and fears. But, I thought if I can put them into a virtual world, and measure their physiology in real time, know what I'm showing them and see what's happening with their physiological reaction, this is brilliant. I can truly individualize the therapy, make it more efficient for the patient. And so I was very fortunate to receive one of the first four PC based VR systems. And I conducted then the first randomized controlled clinical trial, using virtual reality, physiology and cognitive behavioral therapy to treat the fear of flying. And I proved it was successful. The patients that had the Virtual Reality plus the biofeedback had no recidivism after three years. So I was hooked. And I've stayed hooked ever since. 

Kim Bullock:

Wow, that's so fantastic. Yeah. And it seems like La Jolla, that area, and the neuroscience and innovation and, and psychology, and neuroscience is just such a hub for innovation. So it seems like you're in the right place at the right time and all the pieces fell together. So you know, as an international leader now in psychology, where do you think — you're such a renaissance woman here doing so many things, wearing so many hats — where do you think your work has had the most impact? 

Brenda Wiederhold:

You know, I think my work has impact for everybody's life that it touches, whether it's through training programs or treatment, but I'd probably say the most broad impact has been with our military. And so the US military as well as our NATO coalition forces, and at this time, really, that's pretty important. I've trained a lot of the troops, especially in Poland, for the last 17 years prior to deployment. So, we do what is called Stress Inoculation Training. And then we actually have sent systems, virtual reality systems, in theater with the troops (with the US troops), and some of the Navy psychologists and psychiatrists. So we do in-theater treatment, which is we have higher success rates when we do that. And then post deployment, we also treat chronic pain and PTSD, once the troops return. We've done that, again, throughout Europe, and throughout the US in both active duty military as well as our veterans. And we were very fortunate to be funded by NATO to train therapists from 24 different countries on how to treat their troops as well as how to train their troops better so they didn't have the PTSD post deployment. And we've been fortunate to do that, continue to do that, under the nonprofit. We are an APA accredited training program. That's probably the most reach we've had. So a couple of other things. In 2003, I published a workbook, talking about our protocols and how you could use those. So, patients could use it just to understand how they could start using tools to help themselves. And therapists could also have that to use to understand how to incorporate this into their clinical pathways. And that's been translated now into seven languages so it can help more people. A second thing, Giuseppe Riva and I — Professor Riva from the Catholic University of Milan — when COVID started last year, we created something called The Secret Garden. And it is a guided meditation through 3D world. We put that free on the internet. It's now in 14 languages. And we have two more languages coming online in the next month. And we've done a trial with four different countries in Europe showing that it reduces depression, anxiety, and stress during COVID. So I think that's going to continue to have a broad reach and again, freely available for anyone to use. 

Kim Bullock:

Amazing. That is so wonderful. Yes, so a lot of impact in multiple areas. So do you think there's differences in how your work has been received in industry or academia or different countries. Since you're so multidisciplinary and multilocation in a sense, and you're in so many different silos working with different organizations. Is there anything that you've noticed in differences in how people receive things or are impacted and the work you've done? 

Brenda Wiederhold:

I believe until the last few years, what we've really seen is that virtual reality was not being picked up by the private sector, I will have to hand it to Mark Zuckerberg for Oculus because truly it was a game changer for everything, and it kind of opened up the world. But still, then people had to get used to that, that it was available, it was less expensive. And we could use the technology across quite a few platforms. But recently, I would say the last five years, we've seen some people really start to take this into the private sector setting, in a bigger way. And we, I would say we have probably two or three unicorns here in the US, or potential unicorns. So I think we're going to see a lot more of industry picking this up. I'm also seeing a lot more the national health services in the UK has really been a leader in this. But we're also seeing it now in the US with insurance payers, and they're looking at establishing new codes, which some of those will come online actually May 1st. And they're looking at giving incentives almost to use these technologies that we know work better in some instances than just therapy by itself. So we haven't had those incentives in the past. But I think with these insurers picking this up in changing the way that they pay for things, we might see more and more people adopt this. I think that Europe has not adopted this as much in their social medicine programs. But they are looking at that now too. And I've been fortunate. I was originally in Europe as the Senior Behavioral Healthcare Consultant to build the US Army's Medical Research Materiel Command Behavioral Health Simulation Portfolio to help the active duty, the veterans, and their families. And so I talked to a lot of the Ministries of Health, Defense and Education, the European Parliament Commission, et cetera. And I know everybody's on board. We've all just been trying to figure out how to use this. And I think it's starting to come together now. So I'm very hopeful for the future. 

Kim Bullock:

Got it. No, thank you that distinction between the public and the private sector. That's a really good observation I hadn't thought about. Interesting. Okay. Yeah, so since this is Psychiatry XR. What do you think or know about psychiatry or think that it could offer in this space that might be different than other disciplines like psychology? Do we have any role? I'm a psychiatrist, so we're always trying to kind of figure out how we can work together most effectively in behavioral mental health spaces. And how do you see psychiatrists and psychologists working together and the XR behavioral health development together effectively, I guess, or do you have any vision about those roles? 

Brenda Wiederhold:

I actually do. And Dr. Bullock, I think that you are a critical piece to this, I think psychiatrists definitely have a role to play. We've actually done within our own clinic and our own organizations studies combining virtual reality therapy with pharmaceuticals. And we find that in some cases, it works better than just the virtual reality and the CBT by itself. So I think as we see things like ketamine, and other things come online, we're going to definitely need the psychiatrist. And you know, a lot of psychiatrists, like yourself, don't just give meds. They do therapy. They really treat the whole person. And so I think we need that medical expertise that not all psychologists have. And I think we work hand in glove. And I think, you know, we've even at our clinics and in our research programs, we've had the computer scientist and the computer programmers and the graphic artist, and the subject matter experts and the clinicians, and the end users, whether that be a person, a teen smoker, or an autistic child, or a veteran coming back from Iraq and Afghanistan, we've had them involved in the development, and I think we all provide some unique knowledge and skill sets when we start developing these worlds, so we need to be involved in the ethics in setting the standards as well as in doing the research and conducting that research. Because I'll tell you one quick example. I had a wonderful, wonderful biomedical engineer, as a postdoc, and he helped me do a study on fear of blood and needles. And he said, “Oh, but look, this didn't really work because the respiration rate went down on all the phobics but not on the non phobics.” And I said, “No, no, did you look at them, they were all holding their breath, because they were scared.” And so they went, you know, they saw themselves about to get a shot in the virtual world, and they held their breath. So you've got to have those good clinical skills in that observation that non-clinical people don't always have. But again, we all bring a different piece and a different knowledge set. So I think it's good to work together. 

Kim Bullock:

Yeah. I'm really curious about what interventions with medicine, what's your experience where using medication with XR was more effective than using each one alone? 

Brenda Wiederhold:

Yeah, I did a study in Basel when I was living in Switzerland at University of Basel. And we gave one group of the patients cortisol, before we put them into the virtual reality heights environment. And they actually had more effective treatment in a shorter time. And people who did not get the cortisol. We've also here in our clinic in San Diego looked at what happens to a person's cognitions and reaction times when they use allergy medicines. And we did this study for a pharmaceutical firm that was looking at taking some of their medications on over-the-counter for consumers. And we found that some of the medicines had no cognitive or reaction time effects. Others did. And so knowing exactly what stimuli you're giving, like, you know, perhaps a person walking out in front of your car, knowing those things and seeing what that drug reaction is, is really important. So, that one wasn't necessarily making the treatment go quicker, but it was really proving something that was a public safety concern. 

Kim Bullock:

Yeah and there's medications that may have a priming effect for learning, like you're saying, with ketamine or a cycloserine. What's your thoughts on any of these medications that might accelerate the learning curve or desensitization or habituation? Do you think that there are medications that will do that?

Brenda Wiederhold:

I do think there's medications that will do that. We're still you know, really starting to research the ketamine. Those results are starting to come out, they look positive. The cycloserine is a little older. And we've looked at those results, and there have been good results. The only thing that some people are considering is, do we need to use the medications in some cases? Are there side effects that we don't want to deal with for something like phobias? We have to just be aware of that. And it's a risk reward trade off. We've also looked though, and this was really good, there are some people that get cyber sick in the VR, and so they're not able to tolerate the movement. But if you give them some kind of anti motion sickness drug, whether it's over the counter or prescription, they can still go through the virtual reality and have the learning, so they're able to tolerate the movement, but there's no effect on their learning. They're able to transfer those skills into the real world setting. So, that was a really positive thing. Because when we had the older systems, we saw probably, I don't know, a two to 3% cyber sickness rate. And now with the really highly realistic worlds, we're seeing about a 10% cyber sickness rate. So, the fact that the patient can actually take something before the session is really positive. Of course, they have to have somebody drive them home. 

Kim Bullock:

So you're actually seeing an increase in cyber sickness. Interesting. 

Brenda Wiederhold:

Yeah, unfortunately, yeah. 

Kim Bullock:

Okay. All right. So my next question would be, have you seen any conflicts of interests that are problematic or how do you manage conflicts of interest with, industry, business science and research? 

Brenda Wiederhold:

I think, you know, the way I've managed it, and I'm not saying I'm perfect or have all the solutions, but it hadn't been as big a problem before because we didn't have widespread use. But the way I have managed it is number one: what is best for the patient? So, what am I going to use for the patient? Is it my system? Is it somebody else's system? When I do this research, I'm going to be unbiased because I want what is best for the patient or the trainee. And then, as I've gone through my career, I've started actually evaluating other people's software, and they trust me enough to be ethical, and to know I'll be non biased. And so I give them a report and tell them, you know, this works, this doesn't work. And I think that's the thing is, what is your highest standard? And set that highest standard for yourself so that you don't have a conflict of interest. If you know that you do, you need to recuse yourself from looking at a grant, looking at a paper, or doing a research study. 

Kim Bullock:

Can you tell our listeners about the International CyberPsychology, CyberTherapy & Social Networking Conference called CYPSY? 

Brenda Wiederhold:

I'm very pleased to say that despite COVID and despite all the restrictions, we were able to hold our 25th anniversary conference in Milan, Italy, in September 2021. And, we are holding our 26th anniversary conference in Paris in summer 2023. So we're looking at either June or July, we're settling on a date. But, I'm very excited that we are continuing into our next 25 years. I also want to just say something about, because the conference this past time, it was online, obviously because of COVID, but we had participants from 30 countries. Normally we have 20 to 22 countries in attendance. But this time it was 30 countries. It's also very exciting. The journal Cyberpsychology, Behavior, and Social Networking has it as their official conference, and we have a reach into 170 countries. So we truly are a global community and continue to be. And what we try to do is pull in also we have some student awards, and we try to pull in the next generation of therapists, because we do need to do the training. Again I said we have an APA accredited training program under the nonprofit that continues, but we have to have those people learning in their school programs, and then continuing on and saying “I have to use this tool in my practice now that I'm out, or in my research now that I'm out.” So getting those students involved is very important to the conference and just so excited to to have received acknowledgement that we will be having in Paris in 2023. 

Kim Bullock:

Right, I'm starting to plan that trip already. I would really like to attend. That sounds wonderful. Okay. Well, do you think there's any gaps currently in the XR or the mental health field as far as perspectives? Or things that are missing or diversity of viewpoints? And if so, what do you think needs to be done to promote diversity and inclusion?

Brenda Wiederhold:

So as I said, we've always been a very international community. And I would say, even from the start, probably 50% of our participants have been women. So in that respect, we've really had a pretty good gender balance. One thing we did with our conference, which I think helped to even broaden the field more— we actually held the conference at a historically black college and university: Norfolk State University. And because of that conference being held there, it opened it up to a lot of people that didn't know about this field as much. But it also helped them as a stepping stone to start a new master's in CyberPsychology, so that they started to train therapist that could work with more diverse communities. And I think that's so important. We've also seen an uptick in people starting to use the technology for neurodiverse individuals, so people with brain injury, people with autism, or on the spectrum. And I think opening it up to people that are able-bodied, but we've considered disabled in the past, but different kinds of diversity has been important and something that our community has always done. I've always had colleagues, probably just as many if not more colleagues from Europe, that are close colleagues, and we've held a lot of studies that were done in, for instance, Canada, the US, Korea, in Italy, and shown, you know, what are the cultural differences? What do we need to do differently with this software or these protocols for the different cultures? Or how can we use these cross culturally. So, I think we've done a lot but I think we can always do more for inclusion and diversity.

Kim Bullock:

Yeah, what do you think is the biggest challenge in the XR industry right now — behavioral health and XR? 

Brenda Wiederhold:

Good question. So I think there are probably a few challenges we still have yet to overcome. I don't think they're insurmountable, but I think we haven't overcome them yet. The first is the training. Again, I think that psychologists, psychiatrists, mental health professionals in general, need to start learning these skill sets in their programs, whether they're masters level or PhD programs, or MD programs. But we need to start putting these tools into school training programs, we also need to have people give them some incentive. And that's probably the second challenge is getting this paid for. And those new codes that are starting to come online, I think will help with that. We have a lot of the system's being validated, but we still need to do that too. I know my interns, as well as my patients, they come in, and they're kind of confused by a lot of these digital therapeutics and VR systems coming online. Not everything has been validated, not everything works well enough to give it to the patient or have them use it at home. But, as we set up these standards, and these protocols and start the validation process, I think that more and more people will start using it and feel comfortable giving it to their patients. I think probably just really having the therapist in the loop. I would encourage people in the mental health profession to really seek out technologists and work with them. Because I think having us in the loop is a very important piece of the puzzle because we are going to have the patient's best interest in mind. Instead of just pretty pixels. It's not just pretty pixels. It's what cues are in the environment. 

Kim Bullock:

Yeah, very wise words. Yeah, best practices. Yeah, establishing that. But you're right, getting the payers on board will kind of get the train going and maybe motivate us to really create those best practices. Okay, well, in 100 years. What, if you had a magic button, what would you like to see extended reality being used for or what do you see in the future ahead?

Brenda Wiederhold:

You know, I'm not a Facebook employee, or consultant. But I have to give another plug to Mark Zuckerberg. I think the idea of the metaverse, no matter who does it, what company or person does it, I think we'll all have a part in it. But I think it's going to be a game changer. And it's not going to happen overnight, it's not going to happen in the next year or two. We've had pieces of it in the past, obviously with Second Life and worlds like that, worlds that preceded Second Life. But I think being able to go into that world with our patient is going to be very powerful. It's going to enable us to see people that can't come into the office even after COVID is over. We're going to have people that for whatever reason, you know, because they're in a rural setting, or they're disabled, they may not be able to come into the office, we're going to be able to go into the metaverse with them and do the therapy and feel like you're sitting in the room with them. And that's going to help with therapeutic report. I think it's also going to bring groups together that can do group therapy, whether it's therapist-led or on their own peer support. But, I think it's going to be really the game changer for the next 100 years, and it's going to be enabled by things like biosensors and AI. So it's all going to work together and the pieces will fit together and we won't have heavy headsets on our head necessarily. 

Kim Bullock:

Yes, I love that future. Okay. I love it. I love that vision. And I’m kind of right there with you, as I see the same thing coming down the pike. So any last comments to listeners or anything else you think is important for us to be thinking about or talking about?

Brenda Wiederhold:

Yeah, you've been so thorough, and I really appreciate your thought provoking questions. I guess the only thing I would add because I really think this is what it's all about is that my patients have always been and continue to be my best trainers and my best teachers. My patients, you know they might come in with a phobia or even, I had a teenager recently who was on the autism spectrum, and they give me their input, they tell me what they like, they tell me what they don't like, they tell me what I need to change. And they do this because they want to help other people get better. And so they give of themselves, and I just appreciate all the input they give me in the feedback they give me. So I really, really like all the hats I wear, but I learn the most from my patients. 

Kim Bullock:

Yeah, that's such a good point, that patient centered design, innovation, I think too we can't forget that either. We're trying to get the clinicians in there to have a point of view. But we definitely need even more so the patient centered design thinking. Okay, well, great. Thank you for that. And yeah, maybe we even need to do a whole podcast on that at some point. All right. Well, thank you so much! It's been such a pleasure to have you. And Dr. Wiederhold, we thank you for sharing your perspective and insight with us. You have so much wisdom, and we hope that we've given you listeners a realistic dive into emerging XR solutions for psychiatric and mental and behavioral health. And thanks so much for listening. 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 www.psychiatryxr.com. Make sure to subscribe to the podcast and tune in again next month to hear from another guest on XR in psychiatric care. You can join us monthly on Apple Podcast, Twitter, Spotify, or wherever you get your podcast. Kim Bullock produced this podcast with the help of Faaizah Arshad and Jessica Hagen, and we credit are grateful to Austin Hagen for music and audio production. See you next time!