Virtual reality has been making a splash in the gaming and entertainment industry in recent years. Now, as platforms have progressed and technologies have evolved, people are starting to expand their horizons and ask “What if we could use this for more than just entertainment? How can we help use this technology to help people?”
On this episode of HealthChangers, we spoke with Dr. Alison Greco, a clinical psychologist who has been following the advancements of virtual reality for several years. She shares how virtual reality is being used as a pioneering treatment for anxiety, expanding the limits of our imaginations for more comprehensive treatment.
Leslie Constans (LC): Welcome to the HealthChangers podcast, presented by Cambia Health Solutions, where we share real stories of health care transformation from those experiencing it and those helping to make health care more personalized. I'm your host, Leslie. When you hear the term virtual reality, you probably think video games or science fiction. My guest today thinks anxiety. Or more precisely, a new way to treat anxiety disorders.
Dr. Alison Greco, a clinical psychologist, has spent her career following the evolution of virtual reality technology with an eye for how it might transform the way people are treated. I was also surprised to learn some of the other ways VR is being used, such as to treat pain after surgery. When we sat down to talk about her work, I asked Dr. Greco to first explain the nature of anxiety.
“In our day-to-day lives, we take in all kinds of input through our senses and then we process that information in several parts of our brain.”
Dr. Alison Greco (AG): In our day-to-day lives, we take in all kinds of input through our senses and then we process that information in several parts of our brain. We have what I think of as part of the new part of the brain, which would be what is up front, the frontal lobe. That's what you'll hear people talk about where the thoughts come from, rational evaluation and decision-making. That's a part of the brain that we experience all the time and we take in sensory information.
There are older parts of our brain. The one that comes into play quite a lot in anxiety is called the limbic system. The limbic system has two major parts. This is rather a simplification, so just bear with me. We have the amygdala and we have the hippocampus. The amygdala is what we've identified as the fight-or-flight part of the brain.
What happens in an anxiety disorder, especially one that comes out of a really traumatic event or one that we've associated with a traumatic event, is that the amygdala can take a bit of a control over the other parts of the brain. One interesting thing about the limbic system is that we can take input from our senses and it can go directly into the limbic system and be processed. The autonomic nervous system can then react and this bypasses the frontal lobe altogether.
“It really begins to impact our quality of life in everyday living.”
LC: Can you give a little example of that?
AG: Absolutely. Imagine if, evolutionarily, you were out and you were hunting. You saw a bear and you immediately needed to get into fight-or-flight mode. The sight of the bear, especially if you're seeing it from the peripheral vision, will immediately communicate fear, which will then drive the autonomic nervous system to release cortisol, get your heart rate up, get you in physically ready to fly, and get out of there and get away from the bear.
This is an adaptive piece that's pretty important. We can't be evaluating every event that occurs to us, the car crash, the sight of someone who's trying to do you harm, right? We need a shortcut in order to be able to keep us safe and whole.
What happens, though, is that when we bypass the frontal lobe too often, or we have anxiety that is created from an event in the past that we are not able to let go of, we then have a system that was adaptive for a particular situation that begins to run amok. Then it really begins to impact our quality of life in everyday living.
LC: Like a shortcut that short circuits.
“You need anxiety to be something that is a tool that you can use. When it becomes a clinical problem is when you can't turn it off.”
AG: Yeah. Well said. Exactly. When you have an experience that you are unable to let go of and for good physical reasons you need ... your hippocampus is there for memory and helps you to hold onto those traumatic events so that you can keep them ever happening again. When those systems begin to take over and you can't talk yourself out of what you might refer to, and I would use air quotes here, of "an irrational fear." So social anxiety for instance where you know there are no bears.
Nobody is going to come and hurt you. Walking in and having to talk in front of a group of people, where what you're fearing is rejection and emotional harm, can be incredibly debilitating. It uses the same structure that the traditional, physical violence uses and so the symptoms are the same. You have sweaty palms, your heart rate goes up. It's as though your body is trying to tell you that you're in danger and you need to get out of there.
That's where the anxiety really can take over somebody's life is when we can't turn anxiety off in that we need to be able to keep ourselves safe. It's a little bit like saying we don't need pain receptors. You really do need pain receptors. What you don't need are pain receptors in a feedback loop that can't turn off. You need anxiety to be something that is a tool that you can use. When it becomes a clinical problem is when you can't turn it off.
“It’s work…it takes practice. It takes courage, and a good rapport with your therapist.”
LC: Got it. How is it traditionally treated? Before we get into this fascinating subject of virtual reality, how has it been treated up until recently?
AG: What happens with the autonomic nervous system is that it takes in input and it says, "Oh, you're breathing really fast. If you breathe really fast, you must be under stress. If you're under stress, then I need to release all the stress hormones", which then gets you into that feedback loop. One of the very first things that you can do to communicate to your body that everything is fine is begin to slow down your breath.
Be aware and calming in the cues that you're giving your body. In doing so, it will begin to say, "Oh, I can shut off the hormones that are driving the feeling of being under attack." We teach the relaxation techniques as a cornerstone of any treatment for anxiety. The other piece that we include is that we pair those relaxation techniques with the stimulus of the thing that makes the person uncomfortable.
LC: That just sounds awful.
AG: It's work. I will promise you that this is not ... when you finally get to a place where you're ready to confront this, it takes practice.
LC: And courage.
AG: And courage, I would agree, and a good rapport with your therapist. This is important work, but we don't throw you in at the deep end. It's exposure to the thing, but it isn't immediately putting you into the situation and requiring that you swim in the deep end. We pair the practice of relaxation and the breathing techniques and the biofeedback as much as you can do with the slow beginning of exposure. The first thing what usually is, is an imagination.
We begin to imagine situations that make you uncomfortable or we begin to show you a picture of the thing that you're afraid of. Let's imagine that you're afraid of birds and it's a real fear and can be quite debilitating of the people who are massively afraid of birds really struggle to even go outside. It can be a contributor to agoraphobia. You would start with helping them to pair their body reaction to a low-level indicator of the thing that they're afraid of. You begin to get them acclimated to this is a picture of a bird on a piece of paper. I can sit here and I know how to relax myself.
LC: They're practicing those techniques.
LC: Got it.
“It physically actually retrains the brain and the limbic system that this thing, that I have traditionally used as a cue of fear, is no longer a cue of fear.”
AG: You progressively increase the closeness or intensity of the thing that they're afraid of while they increase their ability to relax in the presence of it. It does two things. One is that it increases the ability to relax in the presence of it. I know that I have the skill and I can rely on it when I need it.
Two, it physically actually retrains the brain and the limbic system that this thing, that I have traditionally used as a cue of fear, is no longer a cue of fear. I extinguish that object as representational to my brain of the thing that I'm afraid of.
That's a really important retraining of the brain. You're training your mind to learn how to relax, but you're training your brain to no longer immediately react to the stimulus. Those are the two things we do.
“I have to help you get to a place where you're actually experiencing the thing that you're afraid of, but I'm not always able to put you in that situation.”
AG: It just is challenging in two places. One is that I rely on your imagination, right? I have to help you get to a place where you're actually experiencing the thing that you're afraid of, but I'm not always able to put you in that situation. I have to work with you in your mind, but we're not seeing the same thing.
LC: Yeah. I was just thinking about that. I know someone who has somewhat of an anxiety around driving across a bridge. How would you recreate that experience in a therapeutic setting? That's interesting. It's the imagination. That's where I think where we're leading to with virtual reality, correct?
AG: Exactly. In certain instances, there are therapists who will actually go out into the field with their patients, especially for heights. We would work on going up buildings and being out in the world. The logistics of that are challenging. To your point, where we have gotten with virtual reality is that I'm able to progressively disclose or progressively enhance someone's experience to the point where they really are looking over the edge of a 20-story building, which terrifies me even as I talk about it, and have that be extremely realistic.
“When I remember something, I'm not going into a file and pulling out a memory and it's crystal and lodged. When I do that, it's as though I'm re-experiencing it today and it's malleable.”
What I find interesting about VR and its immersion piece is that while your mind knows your rational frontal lobe, it's fully aware that you have goggles on and that your feet are on the ground and that you are in this little room wherever you are. Your brain and the limbic system absolutely takes in the information that it's getting from your senses, from your eyes and from your hands and from what it is seeing in front of it and takes it as truth. Our brain doesn't really distinguish between what it's currently taking in, what we remember, and what we have in terms of what was produced by our subconscious during dreams.
When I remember something, I'm not going into a file and pulling out a memory and it's crystal and lodged. It's not like replaying a movie. It's actually something that I am going back and pulling out that information. When I do that, it's as though I'm re-experiencing it today and it's malleable. I can change it. I can change the details of it. The dress you were wearing can change color and you don't even realize that you've made that change. You put it back in and the next time you retrieve it, you can change it again. Memory is very malleable. The brain takes the input that it receives from its senses and holds onto that through its processing, various parts of the brain.
LC: Are you saying if you take a patient or client through this process with virtual reality, they can build the memory that this is not ... it doesn't have to be a frightening experience?
AG: Exactly. The brain can't distinguish it. It doesn't distinguish "reality" from "virtual reality". If you think about it, we take input from our senses. If I take input from my senses from sitting here in this room with you but I put the goggles on and I'm getting input now, I'm still getting input from the same senses. My brain doesn't really distinguish. It's important then that we think about the content that we are experiencing in a virtual reality because it's very powerful. It can be really, really uniquely able to work in a therapeutic sense.
“They can begin to look at thoughts of something that are malleable, so you write your thoughts on a leaf and you imagine it going down the stream.”
LC: As a psychologist, how do you see VR transforming your field and the experiences of the people who suffer from disorders like these?
AG: One of the studies that I was most intrigued by was actually not related to phobias, but was related to a personality disorder treatment, which for me is perhaps as a psychologist the most challenging aspect of our psyche and personality to work with. There's a, I won't go into all of the details, but a part of it has to do with self-harm behavior, so cutting and suicidal gestures, sometimes even suicidal attempts.
There's an impulsivity that is related to this. One of the ways that you work with borderline folks is that there's a treatment called Dialectical Behavior Therapy, DBT. A big part of that is skills training and mindfulness and helping with relaxation so that you get less impulsivity. It can be very challenging with folks that are experiencing psychological pain to learn those mindful skills and learn the other steps of dialectical behavior therapy.
One of the ways that they used virtual reality with these kinds of patients was to present them a mindfulness meditation in VR. We often will do imagination to help someone get to a place where their body can relax and they can let go of thoughts. They can begin to look at thoughts of something that are malleable, so you write your thoughts on a leaf and you imagine it going down the stream.
You have a guided process of meditating, but again, you're relying on everyone's imagination and their memory. Often what you're training them to do is return to the guidance and your voice and the breath when their mind wanders. What they found with the virtual reality was that they were able to set the scene and follow the guided meditation while they were also doing some of the skills training.The people who are able to be in that virtual reality learned the skills and reduced their self-harm behavior by a tremendous amount compared to our traditional methods.
“That's where I really see the promise of VR…increasing access for those people and the effectiveness of the treatments that we already have.”
From a therapeutic standpoint, it was greatly exciting to think about increasing access as well efficacy of the treatments that we already have today by using something that is enabling attention, distraction, and focus and goes I think in some ways directly to the brain and kind of skipping the mind, which is something that I have always really struggled in our regular modalities of treatment to really get to those parts of the brain that are causing some of the problem in the limbic system. That's where I really see the promise of VR is not just in what we think of as needing the imagination in order to make the treatment come alive, but also in increasing access for those people and the effectiveness of the treatments that we already have.
"How do I bring technology and software into people's homes so that they have a more effective life?”
LC: So access is about the technology when you mention that.
AG: It is. It's both. I think for therapists, it's an increased effectiveness, but also I think because VR is becoming more available in home and the software is something that will continue to grow and iterate. We will have, I think, a whole suite of therapeutic softwares that people can have access to. I think that even if we were able to have guided meditation in a VR way and do some skills training that someone could do at home, that the impact of that would be a really important place to start.
I think for low-level anxiety or for folks who are not at a place where they are willing or able to get to a therapist, that being able to do some effective in-home training and relaxation and reduction of autonomic nervous and cortisol would be pretty amazing for our culture. For me, it's, "How do I do what we do today better?" Then also, "How do I bring technology and software into people's homes so that they have a more effective life even without having to come in to see a therapist directly?"
“We're at this interesting place where the hardware is accessible, there are companies competing, and the price point has come down and so it's not just for entertainment.”
LC: My last question is, you're not working specifically in VR today, but you've obviously been tracking this over the last decade. Why are you tracking it? What's your continued interest? Tell us a little bit about the evolution that you've seen and where do you see it going next? Would love to have you explore that a little bit.
AG: Absolutely. It's funny how technology will get into waves. I've watched this for a long time and the software needed to be funded and the hardware needed to be funded somewhere, right? It wasn't going to come out of medicine because this is a really novel use for it, so it came out of gaming and it came out of movies. That's where a lot of money is. You were really able to figure out how to move the technology forward because you had a ready audience.
You had groups of people that were really excited about making it a more immersive experience for entertainment. I've been seeing the evolution occur in the entertainment group because that's where the money and the audience is. Now we're at this interesting place where the hardware is accessible, there are companies competing, and the price point has come down and so it's not just for entertainment.
We're now beginning to see therapeutic benefits in a medical setting. We're beginning to see a bit more in the clinical trials in some of the hospital settings. Distraction therapy is one of the major uses for VR in a hospital setting. Distraction really is some of the major elements of very good virtual realities and immersion experience. You can distract the mind from chronic pain or from cravings.
“How powerful is distraction based on the fact that immersion is now really powerful? We don't have the suspension of disbelief because our senses are so engaged.”
In DBT, we call it urge surfing. If you have an urge to do something whether it's self-harm or to eat that cookie that's sitting over there that I really want that I really don't want, then I can feel the urge and I can sit with that feeling. If I'm distracted, then the urge goes away. VR can be incredibly powerful with distraction. What they're finding is that they can use it for surgeries to reduce pain. They're even finding they can do it in addiction therapies and so they're exploring that a lot in the hospital setting.
LC: Do you mean like if a person had a surgery and they're in the hospital recovering but there's pain involved? They can be distracted from that pain using VR?
AG: Yes, that's exactly what I mean.
LC: Versus painkillers.
AG: Yes, very much so. You can reduce the amount of opioid necessary. In fact, they're beginning to actually do it during surgery. If you needed a local aesthetic, they can give you the VR experience and distract you and use very little anesthetic. They're beginning to look at, how powerful is distraction based on the fact that immersion is now really powerful? We don't have the suspension of disbelief because our senses are so engaged.
I was at a local studio recently and got to experience some of their VR. It was a game where we played ... we threw snowballs at each other. There was no way my brain was going to let me not duck. I knew that that snowball was not going to hit me, but it was coming right at me. There was nothing I could do. I had to duck.
LC: You absolutely could not control it.
AG: Absolutely could not control it. No. It doesn't matter that my frontal lobe is telling me that that snowball is not real because my brain-
LC: Or that you're wearing goggles.
AG: Absolutely not. My brain is saying, "Look, my sensors is telling me that this thing is coming right at me." I'm going to react. We really have this sense where senses can be overwhelmed. Pain can take all of your energy and it could be the only message that you're receiving. Novelty and immersion that is taking in all of the senses, the visual field and the auditory, especially be it sounds, it can drown out pain signals.
Once we don't have them, we stop paying attention to them, they tend to go away. Our brain can only process so many things at once. It's perhaps a problem in some ways and in this case is a pretty great thing for us to have recognized. We're seeing it occur a lot in the medical hospital setting. We're seeing a little bit more in the therapeutic from a psychological standpoint occur in the UK.
A couple of podcasts that I listen to talk to some doctors out of hospitals there. Then what I'm seeing is the military is picking up on this. The VA is looking specifically at both biofeedback, hypnosis, and VR in treatments for PTSD. What I'm seeing is, kind of go back to my snowball, I'm seeing a snowball. We're all beginning to look at how far the software's come, how accessible the hardware is now because we've gotten it from the gaming world.
“People are asking ‘How can I use this to improve people's lives? Help me do more of that.’”
We're at this really interesting nexus of people beginning to see that there are markets for this not just in entertainment. We're going to begin to see it become much more mainstream. I'm really hopeful that in the next three to five years, that this stops being something that's novel and then we start talking about what best looks like. We have a treatment modality, we have protocols, we're training psychologists. They're beginning then to give feedback to the people who are giving the software and the hardware and we're beginning to iterate on things that work extremely well for different people and the different symptomology that they have.
Right now, we're just exploring it, but I'm really seeing it pick up speed across the U.S. and across Europe. I'm very excited about where this is headed and so just beginning to talk to other people who are in this field and trying to figure out, "How do you make a business here?" We know how to do it for entertainment and we know how to do it for advertising. How do you then figure out how to make this work in the therapeutic way?
LC: I know you're speaking about this more and more. What kind of reactions are you getting?
AG: Right now, it's really interesting. The people that I talk to in VR have not had a lot of experience from a therapeutic standpoint. It's still novel to come at this from a psychological standpoint, so I'm getting a lot of interesting questions. Also I think the folks that are trained in VR are trained in software or they're trained in entertainment or trained in art. They're not trained in the brain.
Really understanding the impact of their work and the way in which why it is that I have to duck when you throw a virtual snowball at me is really important for the people doing the work. The response is often about, "Tell me more about what I'm doing to people's brains and tell me more about the ways in which I can improve in the areas that I should be wary of." That's one area that people are really interested in.
The other is, "How can I use this to improve people's lives? Help me do more of that." That's what I'm beginning to see a lot of energy around. They know how to entertain and they know how to sell. They want to do that well and get paid for it, but they also really have this desire to help people. I see that the VR community is really energized by that and so that's where I think we're going to begin to make impact. That's what I'm excited about and I see a lot of people in the audience excited with me.
LC: I just want to thank Dr. Alison Greco again so much for being with us today and talking about this fascinating topic and how virtual reality is transforming health care. Thank you for being with us, Alison.
AG: Thanks, Leslie. It was great.