Giuseppe Riva: Body Transfer Experiences in XR
Kim Bullock speaks with Giuseppe Riva on the potential of embodied and body transfer experiences in XR and the role that psychiatrists can play in the evolution of XR's use for mental and behavioral health.
BIO
Giuseppe Riva, Ph.D., is Director of the Humane Technology Lab at the Catholic University of Milan, Italy, where he is Full Professor of General & Cognitive Psychology. Riva is also Director of the Applied Technology for Neuro-Psychology Laboratory (ATN-P Lab.) at the Istituto Auxologico Italiano, Milan, Italy. According to the scientific databases Scopus and ISI Web of Science, Riva is the scholar who authored the highest number of peer-reviewed scientific publications in the fields of “Virtual Reality” in the world.
The following is a transcript of the episode:
Kim Bullock
So welcome back to Psychiatry XR where we aim to inspire worldwide conversations around the use of extended reality in psychiatric care. I'm your host for this episode Kim Bullock, and We’re happy to have Dr. Giuseppe Riva as our guest on the podcast today. Giuseppe Riva, Ph.D., is Director of the Humane Technology Lab. at the Catholic University of Milan, Italy, where he is Full Professor of General & Cognitive Psychology. Dr. Riva is also Director of the Applied Technology for Neuro-Psychology Laboratory (ATN-P Lab.) at the Istituto Auxologico Italiano, Milan, Italy). According to the scientific databases Scopus and ISI Web of Science, Riva is the scholar who authored the highest number of peer-reviewed scientific publications in the fields of “Virtual Reality” in the world. And we're so happy to have Dr. Riva, join us. Thank you so much. It's such an honor to have you.
Giuseppe Riva
Thank you. Thank you, Kim.
Kim Bullock
So I think that we first met in 2017, when I invited you to our Stanford Psychiatry’s annual CME Innovations Conference on virtual reality and behavior change, and to speak about the use of VR and eating disorders. And you were really my very favorite speaker. And I feel and still do that you have the deepest understanding of intuition about the potential of embodied and body transfer experiences in XR and I know you're involved in many XR projects. And I'm just wondering, yeah, what maybe you could start off with just what you're most excited about right now in your work and the realm of clinical XR?
Giuseppe Riva
Yeah, well, I think that the XR now offers the possibility of reducing the distance between the two sides of mental health, biological Psychiatry and psychotherapy, offering the best of both worlds. Well, we you know very well that the mental health treatment world is split into to. On one side we have biological psychiatry. The core of biological psychiatry is the teaching that all psychological states are brain states. So, mental disease are typically described as chemical imbalances in the brain and the success of psychoactive drugs is surely supporting this vision. But on the other side, we have psychotherapy, psychotherapy is totally different because for psychotherapy, the person's environment and life experience are strictly connected to how the brain develops. And psychotherapy tries to modify how people perceive reality because the basic idea you know very well is that behind the psychotherapy is the goal of altering perception of reality, providing new meanings to what happens to people. And well, the two words are very, very different, but we need both, and I think that the XR is the right tool for connecting these two visions because on one side XR, virtual reality augmented reality are experiential technologies. So in VR, you are present in the simulation and when you experience something, you can easily modify an experience that you can modify the meaning of this experience. So typically, virtual reality has been used as a tool to modify the explicit meanings, but also the automatic reactions to a specific experience. On the other side, XR, this is a less known side of XR is also a cognitive technology, because neuroscience, recently underlined that VR and AR are based on the same similar mechanisms used by our brain. So in XR, you have both, experience and cognition, the brain and reality. And if we are able to put them together, we have a totally new tool that can, in my opinion, really enhance the outcome of mental health treatments.
Kim Bullock
Yes, yes. I was thinking, you know, the sort of like, you know, we're understanding more that our reality is set up by predictive coding, that it's a way to alter that coding, in a sense through experience that kind of rewrites code through experience. Is there a project that or something specific that you're doing that excites you more than another project, or is it all equally exciting to you?
Giuseppe Riva
Well, I think that eating disorder is, has been my goal in the last 20 years. So it's not so novel. But it's really exciting for me because eating disorder is probably the most difficult pathology I ever met. Because in eating disorder, you don't have the patient supporting you, you don't have a real clinical alliance. And for these is really, really demanding therapists work in this field, and you know, very well, sometimes burned by this situation. And I feel that now the emergence of the metaverse and the possibility of creating avatars within these because when I started VR, doing my PhD dissertations, having a VR system was really difficult. We had computers that were larger like a fridge, and they cost hundreds of thousands of dollars. And were impossible to achieve for research. Now, for a clinician, you have the tools, you have the technology, it's cheap, it's something that you can use, okay, you can add. I think that for eating disorder, they availability of new systems will be a huge push for improving the treatment. So I'm very happy because one of the main barrier for the use of technology in mental health, the cost of technology is now disappeared.
Kim Bullock
Yeah, I mean, you're bringing up you know, like 46% of adolescents in the US are reporting feeling dissatisfied with their bodies. I know, my generation, including myself, most women feel pretty dissatisfied. And probably not just women, just people in general. Is there a way that you could summarize or or simplify what you know about these kind of body swapping experiences that you've created, and others have that changed body image, especially in the realm of body satisfaction, since we know as you were saying, kind of the research that you can help a lot of people, at least in our eating disorder clinics, you know, you can help people with their eating behaviors and normalize their eating, and they're even, they could know that their images are distorted and be more accurate in their predictions. But the sense of dissatisfaction seems to linger and body dissatisfaction seems to be the toughest symptom to make an impact on in regular CBT for those suffering with it. So yeah, I don't know if there's an easy way to simplify the mechanism or the things that you're thinking might help.
Giuseppe Riva
Yeah, of course, I will try.
Kim Bullock
I know it’s complicated.
Giuseppe Riva
A little complicated, but I will try to simplify as much as possible. The concept of body swapping is the idea that you can use a virtual reality to experience a totally different body. And it's a totally novel experience. When, for instance, I tried for the first time and experienced a female's body, I was surprised. I was surprised because it was totally different from my daily experience. And using this experience, I understood that virtual reality is really the power of putting you in a different body. But why putting you in a different body? Well, as you told before, the merging neuroscience parody is the one of predictive coding. Predictive coding is the idea that our brain functions as an active inference machine, as a simulator that tries to learn the statistical patterns of the outside world, and creates, develops prediction to improve the efficiency of information processing. So the basic idea is that everything including our body is an outcome of prediction. Even if we consider our bodies something as physical as something that you can touch, feel. Well, neuroscience and clinical neuroscience suggested that this is not the case. If we think to the experience of phantom limbs, phantom limb, you don't have any more your leg, but you feel the leg in the space and you can even feel pain in the leg that is no more there. I think that phantom limbs suggest clear with that even the experience of the bodies are prediction. And the problem is that predictions can be wrong. And apparently this is what happens in anorexia nervosa. In anorexia nervosa, the real body is overlapped by a wrong prediction made by our brain and how you can change a wrong prediction. This is the problem because if you use language, if you speak with people, the typical approach of psychotherapy you are not able to achieve a significant change. Even the use of drugs is not effective so much because you modify neurotransmitters but neurotransmitters have a limited role in the content of the prediction. So the only way is to provide to the brain an experience that is not able to predict in advance and putting you in a different body is one of these approaches. So when you are in a different body, you are not able to predict any more how to move in space. And this forces the brain to revise, to change, to readapt the prediction. And in our experience, we have found that the more you are able to use the body swapping to provide these unpredictable experiences of the body, the more the brain is forced to change. It's an automatic process. It doesn't require any conscious involvement of the individual, but it's like wearing a pair of glasses. You don't have to work in any way, but you look better. And this is the real potential of XR.
Kim Bullock
Yeah, it's re-programming of that implicit brain it seems like, those non-conscious processes. Yeah, got it. Okay. Yeah, I was in a game once where you could, you know, change in an Vive, a completely embodied experience where you could pick your avatar and your body. And so I picked this ideal body that I thought was the perfect body. And then I got in it, and they had a mirror, and I started still feeling dissatisfied with it. And I couldn't feel satisfied. So that was such a wake-up call for me. How are you finding these body swapping experiences for different populations? How are you changing? Do they need to be in the experience in a different body for a period of time to really change that implicit brain, or?
Giuseppe Riva
Yes, so yes, well, you can have a first strong change even after one session, but for improving the long term, you need to have more session. And progressively you have to transform. You start from the real body. So you try to mimic the real body of subjects in virtual reality, and you try to make it smaller, so apparently, it should be nearer to the ideal body.
Kim Bullock
Ideal. Okay.
Giuseppe Riva
And then progressively, you move. So we typically use BMI. We start from a BMI of 15. And progressively we move the BMI up to 18— that is the typical range for healthy subjects. And progressively you shift, and the more the subject is able to cope, because the other side is the emotions that you experience when you are in. As you've told us before, there is an automatic change implicit, but also you have to work on the emotions induced by the experience of the, of being in a body that is not your real one, the one you want. And so you use a CBT, typical tools of CBT for desensitize these negative emotions related to the body and you use the automatic change induced by virtual reality to produce these changes. We typically use autobiographical recall, for instance, so we ask the subject to remember positive feelings related to the experience of the current body. So in the past, when they experienced the, a good feeling related to that, and typically is very far in time, but the experience of the body is a very, very strong, elicitor of our memories, and these memories are very powerful for healing the negative emotions related to the subject
Kim Bullock
Got it. So it just sounds like you sort of need the navigator, the psychologist or mental health provider with you during the experience that goes to work together, you're finding. It's, you can't just go in and have some implicit reprogramming.
Giuseppe Riva
Reprogramming works. But it's not enough because you have these negative emotions that are connected to the experience. And you know very well it is like food. You can expose people to VR food. And after sometimes you have an automatic desensitization in relation to the food, but still, the meaning you provide to the food is there. So you need both— working on the implicit level but also the explicit one.
Kim Bullock
Well, so given your presence really early on the scene and these experiments you've done, especially with eating disorders being incorporated into mental and behavioral health, do you see any specific roles for psychiatrists that they may be able to contribute in some way or play in the evolution? Seems like psychologists have been doing this for years and years and we're just kind of coming on to the scene. Are we too late? Do we have value? Or would you see anything that we should be as a field trying to do?
Giuseppe Riva
Well, I think that for psychiatric, the predictive coding world is providing a new door for entrance in this field because the emerging field of clinical computational neuroscience that connects how brain circuits are involved in the predictive functions, well, it's a typical competence of psychiatry. And moving from the static analysis of the brain. So I think that for many times, psychiatrists were focused on localization and neurotransmitters. If they move from a static approach to a dynamic one— so understanding how the brain works during predictions and how this prediction can be modified in some way, and drugs also play a critical role— we know very well that many serotonin, dopamine, neurotransmitters are involved in the predictive functions of the brain. So probably, if psychiatrists try to merge the knowledge of predicting coding with the typical one of psychiatry, they probably may identify new tools and also strategies for improving mental health.
Kim Bullock
Yes, that is good. Good advice. Yeah, we kind of need to take a more holistic network view. And yeah, take another perspective. I like that. And I think we're definitely getting past that neurotransmitter phase. So what if any, are the biggest barriers that you're encountering in your research and in your practice of XR in the field?
Giuseppe Riva
Well, when I started, the biggest barrier was the cost of technology and the development of the tools. Technology was really very expensive, even for programming, a very simple virtual reality experience. Program has required a lot of money. So most of our work was in finding the money for developing tools. Now that the tools are cheaper, and that development is easier, the biggest barrier is related to, I think, the world of psychology and psychiatry. Many colleagues do not understand the potential of this technology, and especially in schools and universities, we don't have many courses dealing with these topics. I struggled a lot in the last years to push to introduce virtual reality course inside the main program, the master's program in psychology. And now I succeed, but still now, I know that in Italy, no other university has a specific course on that on clinical view for reality. And if you don't understand when you're a student, the potential of technology and virtual reality, in my opinion is not so easy later on to introduce technology in the tools that you can use in your clinical practice.
Kim Bullock
Got it, so the training gap.
Giuseppe Riva
Yes. Training gap is probably now the biggest one, and we know that things are moving very fast. We know that now a lot of companies are working for the metaverse, and I'm sure that the metaverse will be big in the last five years and not being aware of what is happening because many colleagues are not aware of what is metaverse, of how many companies are invested in it is probably the biggest area of investment now. And when people invest billions of dollars in research areas you can be sure that things will change.
Kim Bullock
Yeah. Well, what do you think needs to be done to reach optimal success in your opinion, like in the next 20 years for humane extended reality in clinical use?
Giuseppe Riva
Well, I think that also we need easier development tools. So still now, even if development is easier, there are no easy tools for psychiatrists and psychologists for developing the word. We need the Minecraft of clinical tools in VR. So my sons are very able of using Minecraft for developing very complex virtual reality world but we don't have the same tools for psychiatrists and psychologists. If we can have the Minecraft of mental health, I think that the ability of developing different experiences that are tuned, adapted to the characteristic of the final user will improve a lot the potential of these tools for mental health.
Kim Bullock
Got it. Okay. Is there any platform that you think has any promise for doing that for experiments.
Giuseppe Riva
None of them is really targeting clinicians. So they have very good development tools,easier than the typical tools you find in the metaverse arena. But the big issue is that for, for instance, for clinician, assessment is critical. And you don't have any assessment tool inside. For us, for instance, could be very important to know where the patient looks —eye tracking can be very powerful for understanding attention, emotional environment, and so on. But you don't have these tools up to now, even if the technology is available. So you can now buy the Vive with the eye tracker. And also, Meta will release a new eye tracker with this function in the next two months, but you don't have the software that is able to explore.
Kim Bullock
Yes. Yes. I agree. Well, what else do you think you'd like to share with our listeners today?
Giuseppe Riva
I want to tell you about my next research area. Up to now, virtual reality has focused on the external reality. So virtual reality is, uses computer graphics to reproduce the external world but for mental health, I think that we need tools for simulating the internal world. And we are working on a new idea, the idea of sonoception. Sonoception is the use of sound vibrations for stimulating the internal body. It’s a totally new area because we don't have tools for that. My students are developing prototypes for activating mechanoreceptors. So inside the body and outside the body, there are mechanoreceptors that if you touch them, if you stimulate them, you induce a change in the insula, in the heart rate, heart rate variability, in many functions related to emotional regulation. It's a huge area. Very, very exciting, but very at basic level. We started working on that a couple of years ago. And we know that it's possible so we can simulate the internal reality. But we need the technology.
Kim Bullock
Wow, that is, sounds very exciting. All right. Well, thank you so much for your time, Dr. Riva. We so appreciate it. And I hope to have you again. I know there's so much more that we could talk about.
Giuseppe Riva
Thank you, Kim. It was a real pleasure for me and for anyone interested in my work, I have a website https://www.giusepperiva.com/ in which you can find most of my research papers. So please, download them and find new intuition for improving your mental health work. Ciao.
Kim Bullock
That's it. For this episode of Psychiatry XR. We hope you gained a new perspective on the use of extended reality in health care, and thanks 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 and are grateful to Austin Hagen for music and audio production. See you next time.