Dr. Kim Bullock 

Hi, Jessica. So, we're so excited to have Dr. Debra Safer and Dr. Cristin Runfola. Dr. Debra Safer is codirector of the Stanford Adult Eating Disorder Program, specializing in treating eating and weight disorders. She obtained her MD from UC San Francisco and completed her residency as a postdoctoral fellow in eating disorder intervention research with the Department of Psychiatry and Behavioral Sciences at Stanford University.

Jessica Hagen 

Hello everyone.

Dr. Kim Bullock 

Her research and clinical work focuses on improving patient outcomes by conducting clinical intervention trials to establish evidence based treatments, including the use of innovative technology such as virtual reality. She has co authored multiple peer reviewed articles, books and chapters, and presented her work both nationally and internationally. And  Dr. Runfola is a clinical associate professor, also in the Department of Psychiatry and Behavioral Sciences at Stanford University, and has a private practice delivering Clinical Services. Dr Runfola has expertise in eating disorders as well as developing and testing novel clinical programs to enhance outcome and improve access to care. Over the last five years, she has developed and tested Virtual Reality interventions for individuals with disordered eating. She has coauthored multiple peer reviewed articles, book chapters, and presented her work both nationally and internationally. In 2022, she received our Stanford Chairman's Award for clinical innovation and service doctors Safer and Runfola, thank you so much for joining us today.

Dr. Cristin Runfola 

Thank you so much for having us. It's a pleasure.

Dr. Debra Safer 

Yes. Thank you for having us.

Dr. Kim Bullock 

Well, maybe we could start with each one of you about how exactly and why you got interested in exploring XR and VR for eating disorders.

Dr. Cristin Runfola 

I could start sharing for both of us, since it was similar. Actually, we should credit you, Dr. Bullock, because we knew about XR in the psychotherapy space, but really didn't learn much about it until 2017 when you spoke at Stanford's all-clinician meeting, and you shared some of your research on immersive technology for therapy of somatic symptom-related disorders, and it was really intriguing. You also had a lot of enthusiasm about it as a tool in the therapy space. So that's what got us initially intrigued about what had actually been done in the eating disorder space, because we had because we hadn't read anything at that point. So, we delved into the research, and we were pretty surprised to find that actually there were other pioneers like you out there who had been doing it and looking at virtual reality as a tool for assessment and treatment of eating disorders in Italy and Spain. So, Professor Riva, who you've had on the podcast before, was one of those individuals, and then Ferrer-García. And we, you know, as clinicians, we've been working with eating disorder patients for decades, and although we have some really good evidence-based treatments that work, we know that about 50% of people don't fully recover from them, and so we're always, constantly trying to look for what other options might be available. So, we wanted to use this tool because it had a lot of promise with our clients, but we'd have access to it and then we also couldn't find any of the programs that were available in the U.S. So, culturally-relevant programs that were virtual reality based for eating disorders. So, we decided that we wanted to meet up with you and talk about pursuing grant funding to build out interventions that were based in some of the evidence-based techniques that have been used already previously in the literature. Anything you'd add to that, Debra?

Dr. Debra Safer 

I just really want to echo our gratitude to you, Kim, for all the pioneering work you did, the conferences you held on, you know, the use of virtual reality for mental health. You've really just been a leader at Stanford, and you've been so generous with us. We're very grateful.

Dr. Kim Bullock 

Oh, that's so great. Yeah, and you've done so much in such a short time. It's amazing. Maybe you could both tell us a little bit about the VR studies that you've been involved with now and what you're finding because I think it's fascinating.

Dr. Debra Safer 

Yeah, I'll start with a broad overview, and then we each will talk a little bit more about the different studies we've done. First, we mostly have done work integrating virtual reality with cue-based exposure for binge eating, and then during COVID, we used immersive technologies to focus on emotional eating and emotion dysregulation. But Cristin's first going to talk a little bit about our work with VR Cue Exposure Therapy or VR-CET.

Dr. Cristin Runfola 

Yeah. So the reason we chose VR-CET as a starting point or VR Cue Exposure Therapy was because of research in Italy and Spain that demonstrated that it had efficacy and support for working with patients who were refractory to prior treatment, that it outperformed the standard of care in helping those people have resolution from their symptoms. So, we wanted to take what had previously been working in other countries and bring it to the U.S. We initially developed an uncontrolled pilot study looking at feasibility, acceptability, and preliminary effectiveness. So we looked at effectiveness because we were also curious about how this treatment would perform in a real-world clinic setting as opposed to one that's tightly controlled in a research clinic, and in cue exposure therapy, the therapy itself includes repeatedly exposing patients to challenging eating-related situations. So this would be like virtual foods or certain environments where eating takes place, like a cafeteria or a kitchen or a bedroom, and there we would induce cravings and urges to eat and potentially anxiety or uncomfortable feelings, while supporting the patient and working through those emotional states without actually binge eating. So we're working specifically with patients who struggled with uncontrollable eating and who felt a sense of loss of control over their eating behaviors and patterns.

Dr. Debra Safer 

So, maybe I can say a little bit about how we actually divided up the sessions. So we had up to eight one hour VR sessions, and we started out with this assessment phase, which I think was quite interesting. I think we both did, and then the intervention phase, and this was following Dr. Riva's protocol. So again, we want to give him credit for what he did. What our big difference is that we took it into the real world with patients who are actually paying for treatment, so we weren't part of this tightly controlled research setting. But we showed them 30 different foods, and, as Cristin was mentioning, we did have to do some cultural adaptation, because the foods were chosen from a protocol in Italy, and they ate a lot of foods that we don't eat in this country in the same way. So we had to make some changes. It was quite interesting. So, we would show them these 30 binge foods in combination with these different environments, and we were looking for which ones brought about patient rating for their greatest urges and the greatest anxiety. So the computer program then sort of took all the ratings together and came up with a hierarchy of the top 13 most anxiety producing food environments and foods. And so those were what we worked through in the remaining sessions after the assessment. So that phase one was the assessment, phase two was the active exposure, and during that time, we were having patients work through each food by handling the food. We did everything we could to maximize real-world generalizability. So, even though it's a virtual food, there was evidence from the research literature that you could induce cravings and anxiety with virtual foods similar to real foods. So that was certainly important. And so they had the controller so they could bring the food to their face. You know, we asked them to handle it, and there's evidence that handling manipulating enhances, you know, that sense of immersion in VR. We asked them to imagine what it would smell like, even though we didn't have any sort of smell olfactory component to what we were doing. But we would say, you know, could you bring it to your nose? We would comment on that looks really good, or ask them to say more about what they would imagine. And then we would also use any cues in the virtual environment that could trigger more anxiety or cravings. So if a patient had told us about a binge that had taken place in their kitchen, or with bread or something. And I knew some of those details, I might say, "So now it's in your kitchen after your guests have left." You know, "Imagine that the bread is there" and, you know, those kinds of things. So we would use these kind of strategies to help enhance the reality, and then we really wanted to make sure we were exposing the patients. So, you know, if we could tell, it's a little hard, but we were able in this one to see where they were looking. So, we could tell if they were looking at the food, or if they were not, and so we could direct them back if they weren't, and then if they had thoughts that were coming up, we could deal with them. So it's really this opportunity, which we'll sort of talk about later, that virtual reality offers this enhanced generalizability to the real world because it's closer than being in a room with the sunshine streaming in when you're talking about a binge that occurred late at night in somebody's kitchen.

Jessica Hagen 

And so how did clients really respond to this, and what kind of skepticism did you hear about this program?

Dr. Debra Safer 

Yeah, so we tested some of this. We used something called the Client Satisfaction Questionnaire, which is a questionnaire that ranges from between zero and 32 and we actually got a mean CSQR score of 28. So, I think on average, patients had high treatment satisfaction. And 2/3 of our participants rated the VR-CET as excellent and a third as good. That could be a little bit deceiving, because, as you might imagine, some patients, I think, the ones who had higher standards for reality, like, you know, we were using models and the food didn't look completely real, and we would tell them ahead of time, it didn't need to, to bring that up but some patients just it still couldn't feel that real, because we were testing this out before we did our pilot. I was just showing it to my patients and so I still have a patient who just last week was saying, "Oh, remember that horrible thing that you showed me with the food that looks so unappetizing into your..." So, it was just not a go for her. And I think that one of the things in our studies is we were picking people who were interested in doing VR, and so I think a more realistic study would be that we brought people in who maybe weren't and then they told us that this didn't work for them at all. I don't know if that gives you a sense. There certainly was skepticism, and some of it just went beyond skepticism. They tried it and they didn't like.

Jessica Hagen 

Right. Right. So, to circle back a little bit, I'm a little curious. So why is it important to know what type of food causes the anxiety? And, you know, if you're treating several different patients, how are you able to see which foods are more important? Why do those differ from each other?

Dr. Debra Safer 

Yeah, no. It's a great question. So we wouldn't know for sure. I mean, we use the assessment where we show them 30 typical foods that cause binge eating, and the reason that we need high anxiety is that is what we want to expose them to. So if we can't get enough of a emotional sort of response, then there isn't enough to bring the anxiety from a certain level to a lower level.

Jessica Hagen 

Oh, I see.

Dr. Debra Safer 

But I think what you're also getting at, which is interesting, is that everybody has cravings for food and likes certain foods better than other foods. What distinguishes people with binge eating loss of control is that they tend to feel anxious when they're around a food that they are interested in, because they know that they might lose control, and then they'll have the distress and the guilt that they'll experience after the binge episode. So we're looking for that level of both craving, but also anxiety, because that is what we want to expose them to with our thought that if we can expose them to that anxiety so that they could become more comfortable being in that space and learning how to tolerate it, using the skills both exposure, but also some of the therapeutic skills we use in the moment with them, then when they're in their environment at home, that they'll be able to have that pause between the trigger and the response, and it's in that pause that they can make decisions that are more fitting with their values about what they want to do. I think there are many ways that we think that this is a habit like many others, and that there isn't a lot of processing that goes on when people see a food and then they start eating. So they get anxious. They think often that they're not going to be able to resist. They don't want to spend time trying to resist. And they just give in sort of like OCD in a certain way. So it's a very similar thing, I think, is that we want the exposure to be at that highest as we can make it level of anxiety.

Jessica Hagen 

Definitely makes sense.

Dr. Kim Bullock 

This is fascinating. How is this work in VR and outside of research, how are you using it now, if you're using it, and has it changed the way you've practiced now?

Dr. Debra Safer 

I think that some of our current research is an attempt to make it more applicable to our daily work. This original VR-CET, it used a Unity-powered manual build, so it required this very powerful laptop, and that was launched through SteamVR and then to watch it, you had to use the Oculus Rift. We had the Oculus sensors. We had the whole setup and the controllers. It was quite a lot of work, especially if you were not that technically savvy to put together, and that limited our ability to disseminate it. And it would be hard, like in the middle of a session to suddenly say, "Oh, well, why don't we do this?" Because I had to set it up for that particular person where they were sitting, and we just didn't have that many. We had, you know, this computer that was on a cart that we had to move around to the different therapists. So there were reasons that was not so easy. This might be okay to talk a little bit about what we did during COVID, which I think was also influenced by you, Kim, because you were a real pioneer in using telehealth in our department. That had something also, you know, not that many people were really using and in COVID we started using it a lot, but you were quite an early adapter, and I was sort of following you, so that helped that I wasn't so frightened of giving a session via telehealth. But during covid, when we couldn't bring people into the office, we had the good fortune, and I'm giving you credit for everything, Kim, and probably it was but I don't know exactly how we met Riva anymore, or his student, Clelia Malighetti, but Clelia was a graduate student of Professor Giuseppe Riva's, who had worked with immersive experiences that were given in 3D but could be delivered via 2D via screen sharing. So these are sort of metaphorical journeys of, let's say somebody climbing up a mountain with a heavy backpack, and then they have to sort of take the backpack off and examine what's in it, and then make it lighter. And the backpack can represent anything that they need it to represent, but some sort of, maybe emotional thing that they're bringing with them. And the idea being, if you want to keep on your journey, you have to sometimes think about where you're going and lighten the load. And there were, you know, many different metaphorical journeys like that. You know, similar ones, where keeping an eye on where you're going, like being in a boat that has scary things happening in a big storm, and how do you handle that anxiety and still get to your destination? So these journeys were shared, and we had developed a whole protocol, and we did a study testing the acceptability, feasibility, and then sort of a preliminary sense of how efficacious these treatments were for emotional eating in particular and for improving emotion dysregulation. One thing that was interesting to us in the VR-CET study is that many patients, you know the food itself, the site of the food, the thinking about the food, would evoke anxiety and cravings. But for some patients, unless they were also emotionally dysregulated. The food didn't create that kind of craving. That emotional component was very important in getting them to feel that they needed to eat, and that compulsive sense that led to a loss of control. So we were interested in, could we evoke emotions, strong emotions, that are uncomfortable, and help patients regulate them in the moment, similar to the food? So we're exposing, in this case, though, to an emotionally evocative experience, like climbing up the mountain with something heavy, or being on this ship during a storm, and what that brought up for people. So we had a protocol that involved making use of those scenarios and sort of autobiographical memory, and then trying to rescript almost the story, so that they could then at home, when faced with similar sort of emotions, of maybe feeling that they want to give up or hopelessness or there's so much further to go, and that might fit for somebody, let's say, who's in a larger body, who's very uncomfortable and needs on some level, to find a way to keep an eye out for what's most important in their life, and how to get there and not sort of over focus on the details in the moment. These metaphorical journeys were useful. And I found that outside of our protocol, I would be in session with a patient, something would come up, and it would remind me of, what are these metaphorical journeys, and it was so easy because I could just immediately I had them all, I could screen share and that was simple. And in those cases, I could use them and still do, but when something that's harder, like the VR-CET that's not so easy for me to just spontaneously offer to a patient.

Dr. Cristin Runfola 

Yeah, and then we got another set of grant funding through the Hilda & Preston Davis Foundation, NIDA funded us, the National Youth Center Association for the first grant in order to do telehealth delivered virtual reality, and we're working with using a system that is much more easily accessible, something that's portable, and that we could send to patients, to their homes, to deliver, and that's something we're testing, and that will be on the market for other clinicians to have access to, and also will be, hopefully, financially feasible. One of the barriers that we wonder about is still cost. We were fortunate again to have the grant money to purchase the equipment that we needed, and we hope that academic centers will support clinician time to get the training and education needed. We need more people involved in dissemination and implementation like you, Kim, with this podcast. It's fantastic. It's free so that therapists can learn how to deliver the treatment, but how am I using it? So right now, I'm really focused on that specific work, working on developing this near easier version, and also we're adding physiological biomarker data, so we are connecting it with Fitbit Sense, and that will allow us to track heart rate and get more objective measurements of how patients are responding to the intervention.

Jessica Hagen 

That is so important.

Dr. Kim Bullock 

Yeah, are you looking for participants in this study right now?

Dr. Debra Safer 

Not right now, because we're still really working to develop the software, and so we're just testing it ourselves, and you know, with some graduate students who are interested in doing this work. But yes, we're not ready for prime time.

Dr. Kim Bullock 

Okay, so stay tuned.

Jessica Hagen 

Yeah, yeah, you'll have to let us know when you are looking and we can have you back on the podcast.

Dr. Debra Safer 

Thanks.

Dr. Cristin Runfola 

Sounds good.

Jessica Hagen 

Absolutely.

Dr. Kim Bullock 

Well, this is just so fascinating. There's so many different ways of using VR in eating disorders. You're just making me see more than I ever imagined, even in working with you prior, you know you've got cue desensitization, practicing emotion regulation skills. You've got narratives and changing meaning and bringing up memories, connections that weren't there. So what are you excited about for the future of XR and eating disorders? Or, like, in 100 years, how would you like VR to be used, or do you have any visions or things that you're seeing for the future?

Dr. Cristin Runfola 

Yeah, there's so much, but one piece that I would be really interested and fascinated about as a tool moving forward would be to target internalized weight bias and doing that on a broader level within society, but also looking at specific communities where it could cause pretty significant harm to our patients. So like within the medical community, we know that there are implicit biases that people aren't always conscious of that can impact delivery of medical care, including compassion or the types of recommendations that are made in the room that you know someone goes in to get their hearing checked and they're told that they need to change their weight. It can make accessing medical care very anxiety-provoking and invalidating and results in people actually avoiding medical care altogether. So I would love to see this as a tool for targeting implicit weight bias, with like the body swapping protocols and working on theory of mind and empathy. So that's one immediate direction that I'd be really excited about. Yeah. What about for you, Debra?

Dr. Debra Safer 

You know, I think for me, using it for people who not necessarily are binge eating but have trouble, almost in an ADHD way, with preparing foods, with the executive functioning burden of having to think through meal preparation, and part of what leads them to go to snack foods and things like that, is that they just don't want to think about I wouldn't call that an eating disorder, but there are all kinds of issues with eating that are problematic for people that if you could rehearse them, let's say if we had, like, a meal prep kit that was on VR and that I could walk through with them, what makes it so hard, and some of it is a lack of skill. Let's say sometimes people didn't cook growing up. Sometimes there's a stuck feeling that happens as sort of a helplessness around taking care of yourself. You know, I can do it imaginally, but it'd be really nice if I had the little, the meal kit or whatever it was that a person was dealing with, and I could really be with them when they're saying something like, you know, I just want to go for the chips. This is too much. So, things like that.

Dr. Kim Bullock 

Yeah, you could get really specific where the problem is.

Dr. Debra Safer 

Yeah, I think we've also thought that outside of loss of control eating similar to sort of this is exposure for patients with anorexia nervosa to eating. So we do actually have foods in our 30 because, a) not everybody binges on carbohydrate, rich foods. I mean, most people do, and that's why those foods are pretty applicable. But some people don't, but we would really like to have other sort of meals that would be hard for somebody to eat. Things like that. We did make some modifications that there were times like when patients would say, you know, really, "Where are the granola bars? I binge on granola bars." And we hadn't had that in our original list. So we had a chance to kind of redo things, and we added foods. But I think, like Cristin was saying, if it were simpler for us to upload the foods, upload the environments. If we could use phones and Google Cardboard, all those kinds of things, I think would be much better...

Dr. Kim Bullock 

Yeah.

Dr. Debra Safer 

...and I would hope the field would move that way.

Dr. Kim Bullock 

Yeah, great. Circling back to Dr. Runfola, your body swapping comment, could you say anything more? I know that body dissatisfaction is one of the most challenging symptoms to treat, this internalized stigma that people have towards their own body or that others in our culture have and and these changes and implicit biases that can happen with embodied experience like the Proteus Effect that Jeremy Bailenson discovered. Would you like to say more about how you think implicit biases could be changed?

Dr. Cristin Runfola 

Yeah, I could take a stab at that. I think one idea that I had was a body swapping protocol with being able to put yourself in a different size body and have different experiences walking around the world in that body to understand what it's like to have that lived experience. I think that I'm thinking more about being able to understand what it's like.

Dr. Kim Bullock 

For empathy?

Dr. Cristin Runfola 

Yeah, for empathy building, but then I'm also thinking about going back to experiences when someone was younger, where they had either weight-based targeted discrimination and peer-based bullying, and being able to have maybe a third person observer in the room, being able to switch perspectives, being the person who's observing that event happening, and seeing what sort of response gets evoked to think about and reframe the experience in a way that's different from something is wrong with my body or something is wrong with me.

Jessica Hagen 

That's fascinating.

Dr. Kim Bullock

So cool.

Jessica Hagen

If you were actually able to put three different people in a room, and then you're able to change the perspective of the person, you know, that's actually experiencing like, what's it like being bullied? What's it like watching the bullying? What's it like being the person bullying the other person? I feel like that would be so valuable to really enhance empathy, like Kim said.

Dr. Cristin Runfola 

Yeah, and then to be able to evoke an internal voice that would be, you know, sometimes we talk about like building your own internal parents so to speak to help, kind of coach you and support you and be there for you in ways that other people weren't at the time, to intervene and be an ally and to build that moving forward for yourself, and to be able to practice that over and over so also thinking about having it in the room with a therapist but also outside as part of the therapy work that you're doing between sessions to help reprogram the brain.

Dr. Kim Bullock 

Yeah, I don't know if you're actually developing that, or I hope somebody's listening to this podcast, developers and they can start working on that.

Jessica Hagen 

Start working on it. I think that actually Mel Slater. We had Mel Slater on the podcast, and he was talking about something similar to that.

Dr. Kim Bullock 

Yeah, not targeting eating disorders, but a concept like that.

Jessica Hagen 

Yeah, exactly. Yeah.

Dr. Kim Bullock

Yeah. Well, any last points you want the audience to know, or any remaining points you'd like to make that you think are really important?

Dr. Debra Safer 

Yeah. In terms of the body dissatisfaction, which I agree is a very important thing, I think one of the advantages of VR is it allows you to track things somewhat objectively, like where somebody's eyes are going, in ways that are harder to do, especially if you're just with a person. And so one of the things we know about body dissatisfaction, body images issues, is that people tend to focus disproportionately they have attention bias towards the parts of their bodies that they dislike. But you may not realize that unless you actually have some proof where you're looking at an avatar of your body, and you notice where you're looking and so then retraining to sort of look more broadly, which I think is something that we do in a different type of treatment called Cognitive Remediation Therapy, where we work on instead of focusing on the details, trying to see the big picture, so not missing the forest for the trees, yes. And so this is a way to kind of concretize that in VR.

Dr. Kim Bullock 

Yeah.

Dr. Debra Safer 

So just, it's not like a summary of but I think it does sort of exemplify that VR is such a creative tool, and it doesn't replace therapy. It's a way of taking therapies that already exist and helping them be more in that moment. Like it's not that therapy wouldn't talk about a bullying experience, but to enhance it, but be able to see it from different perspectives, like you said. I mean, we process it in a different way when it feels so live. That's just so hard to do in an office, when the sun is streaming and it's the afternoon and you're with this therapist. It is very hard, and a lot of patients will say, you know, "Where are you at night?" You know, you know, and I think that was one of the things that I always felt so bad about, that VR helps so much with, is I feel like I can't still be there at night with them, but I can practice being there with them in a way that's more generalizable than it would be just, you know, imaginally.

Jessica Hagen 

Yeah. Well, I think that the four of us just developed the next billion dollar VR experience.

Dr. Cristin Runfola 

I would love a clone to Debra that I can have access to anywhere, and, Jessica, to have a conversation in the room, a virtual version of you that would generate responses and have these discussions at any time, any day. Yeah, it'd be lovely.

Jessica Hagen 

Absolutely.

Dr. Kim Bullock

All right.

Dr. Debra Safer 

I think patients would say this very exact same thing about you, Cristin. And I do think that that internalization of the therapist voice is something that happens anyway. But if it could be an avatar, like you just said, I mean, that's pretty amazing.

Dr. Kim Bullock 

There's so many possibilities.

Dr. Cristin Runfola 

Yeah, there are.

Dr. Kim Bullock 

All right. Well, thank you so much for joining us, Dr. Safer and Dr. Runfola, It's been such a pleasure speaking with you. We would love to have you again as more studies come out and your research develops. Thank you so much for being here.

Jessica Hagen 

Yeah, thank you both for being here.

Dr. Cristin Runfola 

Thank you for having us.

Dr. Debra Safer 

Yeah, thank you for having us and for all the work you both do to promote XR. Very, very grateful. We benefited enormously.

Jessica Hagen 

Couldn't do without people like you.

Dr. Kim Bullock 

Yep. It takes a team. So, that's it for this episode of Psychiatry XR. We hope you've gained a new perspective on using extended reality in healthcare, and thank you so much for listening.  This episode was brought to you by Psychiatry XR, the psychiatry podcast about immersive technology and mental health. And for more information about Psychiatry XR, please visit our website at psychiatryxr.com, and be sure to subscribe to the podcast and tune in again next month to hear from another guest about XR use in psychiatric care.  You can join us monthly on Apple podcast, Twitter, Spotify, or wherever you get your podcast. Psychiatry XR was produced by myself, Kim Bullock, Faaizah Arshad, and Jessica Hagen. And please note that this podcast is distinct from my own clinical teaching and research roles at Stanford University, and the information provided is not medical advice and should not be considered or taken as replacement for medical advice. And this episode was edited by David Bell and music and audio produced by Austin Hagen. See you next time you.