Dr. Kim Bullock

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 I'm joined by my co host, Jessica Hagen. Hi, Jessica.

Jessica Hagen 

Hello everyone.

Dr. Kim Bullock 

In today's episode, we are joined by Dr. Imogen Bell, and she is an NHMRC Early Leadership Fellow and Psychologist based at Orygen, the Center for Youth Mental Health at University of Melbourne in Australia. She oversees a program of research on the development, evaluation, and implementation of innovative new digital treatments for youth mental illness and health that leverage smartphone apps, artificial intelligence and virtual reality technologies. She brings a translational and multidisciplinary approach to her work that really prioritizes traditional research methods such as randomized control trials alongside industry practices and human-centered design, software development, and business strategy. Thank you so much for joining us, Dr. Bell.

Dr. Imogen Bell 

It's such a pleasure to be here.

Dr. Kim Bullock 

I got so inspired listening to you and hearing you speak at the American Psychiatric Association mental illness advisor webinar, and was really impressed how your career really integrates expertise at a high level in clinical research and industry. I don't think there's very many people like you. Also, I know you do a lot of focus on extended reality as well in both assessment and treatment of behavioral health issues, and wondered if you could just kind of walk us through from the beginning, how you got here, your career path since a lot of people listening might be thinking about careers and trying to mimic some of the things that you've done. Could you maybe guide us through how you got into the virtual reality and extended reality space and the other integration of all these expertise that you've managed?

Dr. Imogen Bell

Yeah, the career journey. What an opportunity to reflect and think back. So, yeah, I did my undergraduate in neuroscience and psychology, so I was always super interested in how the brain works and over time, got more and more interested in, you know, psychopathology, particularly psychosis actually. I was really fascinated by how when the brain is having trouble making sense of reality through experiences, what was really going wrong there and I ended up doing a PhD in Clinical Psychology. So, in Australia, we have these programs, I think it's the same in the States and other places as well, where you can do your training to become a Clinical Psychologist alongside your PhD. So that was great because I can really have a focus on the clinical training side, whilst also, you know, getting training in research. And that combination has always been fascinating, and I think is a continual thread through the work that I do now, you know, working clinically with young people as well as developing new technologies to help them with mental health.  So my PhD was focused on implementing and integrating digital technologies within treatment to try and kind of improve the effectiveness of treatment, really, this is where I'm interested in. There's a lot of conversation, I think, in the research earlier on in the digital mental health field, which was about technologies improving access to care through apps and whatnot. And I'm really interested in how technology can actually improve the effectiveness. And I think with virtual reality in particular, this is, you know, some of the results that we're seeing from clinical trials of really novel, innovative, you know, interesting different ways of delivering treatment have shown us, you know, how we can actually turn up the dial on the effectiveness of treatments. But towards the end of my PhD, which I finished in 2019, my partner bought a virtual reality headset. Actually, it might have been a couple of years before. He was, like a very much an early adopter, and the first time I put it on, I was completely blown away by how immersive it was. And since then, one of my favorite things to do in my career is actually, like demos of VR. And I always ask people, have you tried it before? And a lot of people say no, and I say, goody, like, yeah, because my favorite thing is showing them for the first time, because it completely inspired me. You know, if we can control the experiences that people are having, and if we could harness that for good, a lot of people the reason why they end up having mental health difficulties is through experiences, whether it be trauma or challenges in functioning with everyday life that kind of perpetuates and builds the mental health issues that they have. I see virtual reality as having the potential to control people's experience in a positive way, which is where a lot of the innovation has happened in the mental health space in treatments and the effects from RCTs are showing us that it really works.

Dr. Kim Bullock 

Yeah, got it. You really wanted to kind of focus on the effectiveness that you just kind of fell into this from a gaming experience.

Dr. Imogen Bell 

Yeah, exactly.

Dr. Kim Bullock 

Yeah and integrated it into the work that you're already doing.

Dr. Imogen Bell 

Yeah, that's right. I ended up approaching my mentor and now the Director of Orygen Digital, which is where I work. So Orygen is a youth mental health organization focused on doing research in youth mental health, policy, and also services. And Orygen Digital is the arm of Orygen that's focused on using digital technology to enhance youth mental health care. I approached the director and said, I really want to work with you. So Mario Alvarez is his name, and I was so passionate and inspired by the work that he was doing. You know, he was really interested in VR, so we got together. I just cold emailed him and said, I had been looking for a postdoc. And he said, "Oh, we're looking to establish a whole new area in virtual reality within the Center for Youth Mental Health. Come and help me do it." So, that's what we did, and that's what I've been doing for the last four years. We've built a VR lab here. We have a team of 12 now-VR developers, professors, peer workers. We work with young people a lot. So we've actually built this whole new area of VR treatments for youth mental health over the last four years at Orygen Digital.

Dr. Kim Bullock 

Oh, got it.

Jessica Hagen 

So, when you say that you work with developers, what kind of platforms are you developing?

Dr. Imogen Bell 

So, we develop a number of different treatments. We've kind of got three core focuses. One of them is on virtual worlds. So we built a platform called Orygen Virtual Worlds, which is a little bit like one of those old gaming kind of Second Life or the Sims. It's kind of a 2D version, which we're looking to kind of integrate into immersive VR in the future. But this came about mainly through COVID-19, we found that telehealth became massively adopted, but these platforms like Zoom and Teams were really not fit for purpose. Young people hated them. So, we thought that virtual worlds could be a way to deliver care that's more engaging, immersive, and social as well. And we ran a pilot that had some really promising results.  So we built that ourselves. We co-designed it with young people and clinicians. We have developers on the team that built that prototype. So that's one area. Another area is in VR, sort of gamified therapeutic experiences in VR that are kind of translate therapeutic skills like cognitive diffusion and things like that, mindfulness, into sort of fun and interactive games that clinicians can use to teach young people, and young people might also be able to use it independently in a self-guided way to learn and practice those sorts of skills.  So, again, we've co-designed a prototype called MIND at the moment, and we're looking to run a pilot implementation effectiveness trial next year and release it eventually. We have a big focus on implementation and scaling, so not just developing and evaluating and sitting it on the shelf, we really want to make sure that at the end of the day, these tools end up in the hands of people that can actually benefit, and we're lucky enough here to have a lot of internal resources in supporting that focus, because it's really an expertise that sits outside the traditional sort of research realm.  The third area is an immersive VR therapies, more traditional kind of exposure-based therapies that make use of real world, you know, environments and a psychologist would sit with a young person and deliver, you know, cognitive behavioral therapy within these immersive environments. We've got a big area of work going on in psychosis actually, led by Dr. Roos Pot-Kolder here at Orygen. So, those are the core focuses that we have

Jessica Hagen 

That's fascinating.

Dr. Kim Bullock 

Really fascinating, and do you know when these might be available to clinicians? Are they already available, and are they getting to market or is there a way to try things out, or where are they in the translational process?

Dr. Imogen Bell 

Yeah, they're at different sort of stages, mostly at prototype stages, and we need to do some more development, and we need some funding to actually get the platform ready so it's fit-for-purpose to iron out some of the kinks, but we actually are already looking to implement that within our own services over the next 12 months.  So, in terms of scaling it beyond those services, that's where we start to have to think about things like, you know, funding models and scaling plans and what sort of support might we need to scale that up. There's various models that we need to sort of figure out. In terms of MIND, which is the kind of gamified therapeutic experiences, I would say within the next 12 months to 24 months that might be available to actually download and use. But again, we're in that stage where we're trying to figure out, you know, how that's going to look in practice.

Dr. Kim Bullock 

Yeah, that's always, it seems like, a challenging part. I do think in your system it sounds like it is a bit easier to be able to combine the clinical expertise and a PhD with the rigorous scientist, and so you got to kind of do both. And then I was also kind of sitting back and envy looking at how you're able to effectively partner your academia and industry, and how you work that relationship with Orygen and your university. Is it embedded in there, or how does that actually work and how do you manage the conflicts of interest and those types of relationships?

Dr. Imogen Bell 

It's a great question and, you know, I think Orygen and Orygen Digital is incredibly unique. I think we're actually at Orygen Digital, the world's largest organization that's dedicated to researching and also implementing and scaling youth mental health digital technologies. So, it's quite unique because everything is in-house, although we are now exploring more and more partnerships that we might be able to utilize in order to take things to scale.  So, for example, Liminal VR is a VR company here in Melbourne. They partner to develop VR products, but they also have their own platform that's available on the Quest Store, actually.

Dr. Kim Bullock 

Yeah, yeah. I've tried them.

Dr. Imogen Bell 

They're great and real fantastic, you know, guidance for us. So they're helping us build the latest version of MIND, and we're exploring whether to bring that back in-house and all sorts of things. But they've been great. But Orygen is actually the Center for Youth Mental Health within the University of Melbourne. So, it's a specialist research institute as well as a translational organization and a clinical service. So everything is, you know, under the one umbrella, and it's fully embedded within the university. So the research arm is the university. So I'm technically employed by University of Melbourne as a Researcher, and sit within Orygen. And then Orygen Digital is sitting within Orygen.  You know, most of our funding actually comes from the rollout of our biggest flag, our flagship online therapy platform called MOST, which has been rolled out across 50 plus youth mental health services, which we call Headspace here in Australia, funded by state and federal governments. So that's brought a lot of capacity in terms of, you know, we have a whole engineering team. We have a whole operations and strategy team who are amazing. So everything being in-house means that the whole ecosystem of Orygen Digital benefits from that expertise, and I think that's critically been how we've we've able to mature to the point where, you know, we're an organization that can take things to scale in that way.

Dr. Kim Bullock 

Yeah, I would think that would really help the translational process.

Dr. Imogen Bell 

Yes.

Dr. Kim Bullock 

Do you see any conflicts or problems with the industry, might have different goals than academia or keeping tabs on each other, accountability, or licensing, even like who owns the license and stuff like that?

Dr. Imogen Bell 

I know exactly. I mean, we navigate this. Luckily, we have people in the team, and also at the University of Melbourne as well like working with the teams that you have available to navigate those things at a very early stage helps us to do that. Like I work with the General Manager of Orygen Digital, John Meyer here. He is phenomenal. You know, if I ever have any questions about those things, I go straight to him, and he knows what to do. So having that expertise there is sort of great. But we do build things in-house, and if we have an external company like Liminal, who are building something for us, we pay them to do that on a contract basis. We retain all of the IP, but knowing that landscape, and you know, knowing where the dangers are, is complicated.  We are, you know, interested in exploring other models as well, where we might be able to more formally partner with an industry, where we sort of share IP or, you know, they are responsible for taking things to scale, and we retain our focus on the evaluation and the development of the innovation. With the Wellcome Trust, I don't know whether people are aware, but there's a big funding opportunity at the moment at the Welcome Trust, a UK funder, and they've put a call out for digital interventions to be developed and evaluated, and they're calling for partnerships between academic organizations and companies that can take to scale. So I think more and more we are moving towards a model where academics are partnering with industry to get things out there.

Jessica Hagen 

That's good. It kind of solidifies that validity a little bit too, right, of these platforms?

Dr. Imogen Bell 

Yeah.

Dr. Kim Bullock 

Yeah, and thinking about we had the Chariot Program and their InvinciKids and they're looking for VR pediatric programs, and that's kind of what they do, the InvinciKids, too. So, you guys might be a good partnership too.

Dr. Imogen Bell 

Yeah. Yeah. Yeah. You've got to be out there and talking about your work. You make these connections through word of mouth, these partners, and you just never know how things are going to evolve. So that's what I always think about, you know, how do I get the work out there? How do I be open to opportunities to partner and just follow the leads?

Jessica Hagen

I'm just so curious about one thing. So you do VR, you have different, you know, extended reality offerings, right? But then you also do a lot of other type of digital therapeutics as well. So when you compare the effectiveness of the two, have you found VR to be more effective or less effective or is it similar? How has that gone in your experience?

Dr. Imogen Bell 

That's a really, really great question, because I used to think about this differently, but based on the results that we've had come in, it's kind of challenged me a bit, because the other area of my work is on a smartphone app called Mello, which is designed to help young people with what we call stuck thinking, which is worry and rumination. So it gives them strategies to use in the moment that they're stuck, to get unstuck, and it can help with depression and anxiety because stuck thinking is a big driver of those problems.  So it's a fully self-guided app, which they can use it on their own. A lot of clinicians kind of use it within their treatment too we've been hearing because that's been released now you can download it for free in Australia. Hopefully over the next few years, you can download it elsewhere as well, but we did a randomized control trial of Mello and we found that after young people with depression and anxiety and problems with stuck thinking we're using this app on their own without any sort of human support for six weeks, the effects that we saw from that were really quite phenomenal. And we found that eight out of 10 young people, so 80% of the young people who used the app, found improvements in depression, anxiety and stuck thinking relative to the control group, and the size of how much they improved was about equivalent to what we tend to see in six to 10 sessions with a psychologist. So this is quite phenomenal because you know, the opportunity to provide access to effective care in this sort of scalable way is quite important. We need to do follow-up trials to confirm this with larger sample sizes and whatnot, but at least it gives a bit of a proof of concept about the opportunities for even just self-guided apps. Engagement was quite good with the app as well, which has traditionally been an issue with self-guided apps.  So, that gives me a lot of enthusiasm about the opportunities for smartphone apps, particularly ones that target precise mechanisms, like stuck thinking and do it in a way that is very timely and personalized for people; I think that was part of the difference with this app relative to others. But if you look at the research more broadly, like meta analyzes of randomized control trials from smartphone interventions, online therapy platforms and VR treatments, which are probably broadly the buckets of digital interventions that have been looked at, overall, so not just youth, but also adults, I think that we see the largest effect sizes in the VR treatments, definitely. Particularly in really innovative VR treatments that take a quite unusual approach. We see really large effect sizes.  There's a treatment called AVATAR Therapy that's being developed in King's College London. We're doing a trial of this here now in Australia, called Amethyst, run by Neil Thomas at Swinburne University. But this is a treatment for people who are distressed by voices in their head or hallucinations, typically seen in schizophrenia-type presentations, but also other disorders too, and it involves creating a virtual representation as an avatar of the voice that they hear in the head, and then the therapist does the kind of role play, playing as the voice, and switching between them and the therapist to try and guide the person to develop a more assertive and healthy relationship with the voice. These voices can be quite derogatory and mean, and they can tell them awful things. They can be distracting, so really helping them develop, you know, a relationship that's boundaried and healthy for them can help improve their lives.  They've done trials showing that the effect size of these treatments is really huge, and there's been people in these trials that were hearing voices for 17 years that stopped hearing voices altogether after receiving this treatment. And for me, as a researcher on the hunt for ways to really dramatically improve effect sizes for these treatments, that is the most exciting thing to me, and that trial result is also one of the reasons why I'm so invested in VR when I see just the opportunities we can have to improve lives,

Jessica Hagen 

They just completely stopped hearing the voices?

Dr. Imogen Bell 

Yeah.

Jessica Hagen 

How is that possible?

Dr. Imogen Bell 

Well, yes, I could go into the mechanisms of AVATAR therapy for a whole hour.

Jessica Hagen 

I know I could talk  about this for a long time, so.

Dr. Kim Bullock 

I think you're right. You know, there's a lot of efficiencies that you can get and more convenience with evidence-based...

Dr. Imogen Bell 

Yes.

Dr. Kim Bullock 

...treatments, but psychosis and primary psychotic disorders, that's what's really exciting, because it looks like you can get even superior results, like you're saying.

Dr. Imogen Bell 

Exactly, yeah.

Dr. Kim Bullock 

What are you most excited about in the future in the potential of immersive technologies and behavioral health? Like in 50 years, what do you think is going to be really cool about how we could use immersive technology for mental health?

Dr. Imogen Bell 

I think it comes back to what I mentioned before about the therapeutic power of controlling people's experiences. As I said, you know, that's the way that the problem happens when we think about mental health. That's how the problem develops. Through negative experiences, through the ways that people respond to their environment, can kind of set them down a trajectory of really bad mental health.  We can harness virtual reality because of the control that we have over the environment and people's experiences, we can control their experience in a way that can take them out. So it can give them a journey to recovery, you know, of repair, of positive and joy within their lives. It can give them skills to function and flourish. I think it's this flourishing that we're really interested in here, too. It's not just about helping people to cope. It's also about giving them joy in life.  Something that Roos Pot-Kolder and I talk about a lot, actually, is how can we use VR to give people joy in their life when they're out in the real world? It can set them on a trajectory so that they can experience joy in the real world.  So, fundamentally, that's what excites me and when I look at the trials that are being done and the innovation, fundamentally, that's the thread that I'm seeing that really excites me, and it's virtually endless. I think that the technology itself will just get better and better and better to the point where, first of all, it's more comfortable to use, it's more seamlessly integrated within care systems and people's everyday lives.  So that the moment the Oculus Quest 3, which is what we use, you know, it's still quite clunky and heavy. The UX needs to be improved. It's still something that people are getting used to, and I think that in the near future, we're really going to see dramatic enhancements in how the smoothness of that experience, both in a physical hardware sense, but also in a software and a UX/UI and just it being embedded in people's lives and the, you know, opportunities there in the same way that smartphone apps are in people's pockets, VR headsets being available for people to frequently be exposed to positive experiences, therapeutic experiences, in a way that is going to maybe change their lives. That's what I'm the most excited about, and I hope to see we get to a point, hopefully not in 50 years time, maybe in 10 years time, where we've reached that.

Jessica Hagen 

I have a feeling that AI is probably going to help accelerate that a lot faster than 50 years too.

Dr. Imogen Bell 

Absolutely. I should mention also AI, because we are doing work on that at the moment, because, you know the AVATAR therapy that I mentioned, for example but you know also the therapies that we've got here, they rely on being delivered by a therapist, usually a clinical psychologist actually, who specializes in this. But they're already developing, so I think you're right, it will happen sooner, rather than later, automated, sort of AI-driven treatments too.  So imagine a sort of AI avatars that sit within these virtual environments that could actually be programmed in a way, you know, they are your clinician. So you sit down in a room with them, they're there, and they're like, let's go and let's go and do this, or let's go and do that. Or generative AI is getting towards the point that I'm convinced over the next probably five years, we'll start to really see AI therapists that are capable of delivering certain therapies that will really reduce the burden on the mental health care system and hopefully mean that clinicians can play an integral role of supporting that technology-based care or make sure that their efforts are being focused where they really need it.

Jessica Hagen 

I think that's one thing that we could have an entire separate episode about-how AI is going to affect psychiatric care within the virtual reality space. Absolutely.

Dr. Imogen Bell 

Absolutely,

Jessica Hagen 

Both negatively and positively.

Dr. Kim Bullock 

Yeah, and then maybe some of the barriers too. I know the environmental costs and the carbon footprint now is kind of a current issue that needs to be addressed too. But...

Dr. Imogen Bell 

Yeah.

Dr. Kim Bullock 

...that could be a whole other episode. But thank you so much. Is there anything else you would want the audience to know before we wrap up?

Dr. Imogen Bell 

It's worth mentioning, actually, that we've just had an article that will be published over the next couple of weeks, if not already, in Nature, that reviews the whole field for mental health. So that's something that we've brought. Myself, Roos Pot-Kolder, and Professor Lucia Valmaggia, who's here at Orygen and is the head of the VR here, we brought together experts in the field and and reviewed the literature together on VR treatments across the board for mental health and where's the field going? What are the priorities as the next steps? So, I really would direct people to read that paper when it comes out.

Dr. Kim Bullock 

Oh, that'll be really nice. Yeah, to get those overviews are so wonderful, and I know they take a lot of work, though.  So, thank you for doing that. All right. Well, thank you again, Dr. Bell for coming. It's such a privilege to have you here.

Dr. Imogen Bell 

Yeah, absolutely.

Jessica Hagen 

Fantastic to have you.

Dr. Kim Bullock 

Oh, absolutely. Thank you for having me. And 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 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. Be sure to subscribe to the podcast and tune in again next month to hear from another guest about XR in psychiatric care. And you can join us monthly on Apple podcast, Twitter, Spotify, or wherever you get your podcast.  And Psychiatry XR was produced by Dr Kim Bullock, Faaizah Arshad, and Jessica Hagen, and please note that the podcast is distinct from my 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. This episode was edited by David Bell and music and audio produced by Austin Hagen. See you next time.