Hello and welcome. I'm Dr. John Torrence, the Director of Digital Psychiatry at Beth Israel Deaconess Medical Center and technology expert for SMI Advisor. I'm pleased that you're joining us for today's SMI Advisor webinar, Extended Reality Technology Treatment for Serious Mental Illness. Next slide, please. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get answers you need to care for your patients. Next slide, please. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one continuing education credit for psychologists, and one continuing education credit for social workers. Credit for participating in today's webinar will be available until October 24th, 2021. Next slide, please. Slides from the presentation today are available in the handout area found in the lower portion of your control panel. Select the link to download the PDF. Next slide, please. Feel free to submit your questions throughout the presentation by simply typing them into the question area found in the lower portion of your control panel. We'll reserve about 10 to 15 minutes at the end of the presentation for question and answers. Next slide. Now, it's my great pleasure to introduce you to today's faculty for the webinar, Dr. Kim Bullock. Dr. Bullock is a Clinical Professor of Psychiatry, is a Clinical Professor of Psychiatry and Behavioral Sciences at Stanford University. She's a diplomat in the subspecialties of behavioral neurology and neuropsychiatry and lifestyle medicine. She's currently appointed as a clinical professor in the Department of Psychiatry and Behavioral Sciences within Stanford School of Medicine. She is the founder and director of Stanford's Neurobehavioral Clinic in Virtual Reality and Immersive Technologies Program and Laboratory. She is also a leader and pioneer in telehealth services using extended reality. She's published numerous peer-reviewed articles and is a Cambridge and Oxford Press author on the subject of functional neurological disorders. Her primary clinical research interest is exploring the use of technology for trauma treatment in psychiatric illnesses, especially those involving disruption of bodily perceptions and functions. So, Dr. Bullock, thank you so much for leading today's webinar and take it away. All right. Thank you so much. I'm so excited to be here. I did want to say that I do not have any conflicts of interest related to this subject matter, and I also wanted to give you a little context about how I got involved in XR. So, I'm a little bit of an outlier as a psychiatrist. I really focused on behavioral intervention, so have really spent the last 20 years being a psychotherapist doing cognitive behavior therapy, other behavioral therapies, and dialectical behavior therapy and group therapies. And I only accidentally got involved with VR as a neuropsychiatrist. I was trying to develop some physiotherapy for people with functional neurological disorder. And when I looked into the literature on XR and virtual reality, I realized what an enhancement that would offer for my behavioral treatments, and started just to explore this. And so, I'm hoping to excite you and motivate you to do the same and to explore like I'm doing right now. And at the end of this lecture, hopefully you'll be able to review how extended reality is currently being used for serious mental illness, also analyze the clinical evidence for its use in SMI, and then also know about the resources for getting more training and really diving in and getting that clinical experience. So, I was hoping to do this by dividing this lecture into four components. The first, we'll just have a little primer on the vocabulary and basics of extended reality. And then we'll move into what is the evidence and the research on XR that support its use in SMI, and then dive into how you would actually add it into whatever practice you're doing. And then lastly, I like to kind of think about the future and brainstorm ideas and potential of XR for the future. That's super exciting. And so, let's first start with what the definition of XR is. And if you're like me, when I first heard the term, I got a little nervous, like maybe there's some type of technology that I missed the boat on and I'm not aware of. And actually, you can just kind of rest assured, it's not a new technology. It's an umbrella terminology for all the realities that are currently going on, as well as a term that could be used to bundle future technologies. So, it really is a term that's being used to bundle virtual reality, augmented reality, mixed reality, and any other future realities. And so, I'm going to dive into each one of those definitions of what those realities are as well. And we're going to start with the most basic, which you probably heard about somewhat in popular culture, at least virtual reality. So, the definition of that. So, right now, actually, it can be considered any 3D image experience. And so, you may find in the literature that people, even a television screen that's 3D that's being interacted with can be considered virtual reality. But for the purposes of this lecture and what I'm going to be talking about, I'm going to be using the definition more for virtual reality that completely replaces the real environment by head-mounted displays. And so, this type of virtual reality really takes you someplace or somewhere else. And it usually incorporates visual and audio feedback, but it can use other senses like smell and touch and vibration. And it does this by using the X, Y, and Z axis of your head movements. And if you want to get fancy, you can use the terms yaw, roll, and pitch tracking. And it does this, and it monitors head movement in space. And what it does is it replaces visual reality by just the reality of motion in the head, in the X, Y, and Z axis. And this informs a computer-generated algorithm that creates an experience that hopefully can create emotion, cognition, and behavior. So, that's kind of the mechanism in a very crude way of how I'm explaining it. And it is now becoming much more ubiquitous and popular culture and available to many more people, thanks to the fact that it now, we can deliver it on mobile devices. So, in about 2015, experiences started to become available on people's mobile phones. And for just a few dollars with a piece of cardboard called Google Cardboard, you can just slip your camera into these devices, and you can have a virtual reality headset. And so, this was a real game changer in that a lot of people started to have access to this. So, there are different types of headsets now you can buy that are a little fancier and more comfortable, but they're all based pretty much on this Google Cardboard model. And they can be anywhere from $20 to $40. And then there were some companies also exploring built-in sets with their own mobile devices like Google Daydream or Samsung. But it was really a game changer to have such availability, and it started to be thought about and used more. And one of these concepts I think you should just be familiar with is this construct called sense of presence. So, this is a psychological terminology used to talk about the subjective feeling of being there. So, it's really a measure of a device's robustness and ability and ecological validity to be able to trigger a sense or an experience or trigger emotions. And it's frequently divided into three aspects. So, there's the social sense of presence, how able it is to convince you that you're in an environment and interacting with the environment or other avatars or people in the environment. There's also how convincing it is as far as spatial or the location in the environment. And then finally, we're going to talk even more depth about this ownership and self sense of presence. So, how convincing is it for you that you own a body in this environment? And so, what's really interesting is it is actually a marker and correlates with a transfer of skills and learning, mostly procedural learning. So, that and fine motor and gross motor learning. It may help motivate and enhance other types of learning like knowledge learning, but the real correlation happens with this procedural learning. So, for example, a surgeon, if they're in a more robust convincing sense of presence environment, are going to learn how to, let's say, close a wound more quickly in a simulation environment. So, it really enhances skills like surgical fine motor skills, but it wouldn't necessarily enhance how quickly that surgeon could learn the 12 cranial nerves, that knowledge-based environment. Might make it more fun and more motivating to learn, but it doesn't have that same correlation. And then the other terminology you'll hear a lot is immersion. So, that is basically the ability of the device to create that sense of presence and how robust it can do that. And it actually can happen because our nervous systems are so amazing. We can be fully immersed within five to six seconds with good devices. And you can really increase the sense of presence and immersion using embodied virtual reality technology. And so, what's different about that is not only are you taking the head movements, but now you're taking your entire body movements and tracking your limbs, hands, other parts of your body, which really increases the immersiveness and the sense of presence. And that is used, not just the head, but the entire body used to inform and generate experiences. And this also allows sensation to be modulated, not just cognitive experiences or emotional experiences, but you can really change some sensation. And I'll be talking more about that as well. And around 2015 as well, it really came into popular culture and was a game changer because the gaming industry now came out with some devices that were very similar to what was only available in million-dollar laboratories, which now enabled embodied avatar experiences in VR. And so, the HTC Vive and the Oculus Rift were one of the first ones to emerge to allow this. And now, devices at a lower price, such as the Oculus Quest, are available that do that similarly, although most of those, the lower-priced ones, are doing just the hand tracking. But also, what's coming out last week, Facebook and Oculus reported that they're going to be doing facial tracking and eye gaze tracking. So, that will also be able to go into the algorithms and really also up the ante for the social sense of presence. The other really amazing thing about VR is that you can force perspectives. So, you can have a, like, being John Malkovich sort of experience, where you're ported into another body or person and have a first-person experience, let's say. So, we say the egocentric point of view, which is the experience we mostly have just being alive. But you can also force this kind of theory of mind, allocentric, or second-person point of view, where you can watch yourself and how another person might be experiencing you. And Mel Slater has done some really intriguing and interesting reports of self-counseling, where people really enhance their ability to feel helped when they, for example, talk about their problems to an avatar, a Freud avatar from an egocentric point of view, and then switch to being Freud listening to their problem. And so, you can force, passively, have a person be able to look at themselves from a second point of view. And you can also do a third-person point of view. And any of you are out there that do therapy or bibliotherapy for trauma, you know this linguistically is quite important in narratives about trauma, that helping people right their trauma in a third person, if they're over-engaged and over-emotional and flooded, can be quite helpful and transformative. And now you can do it not just with language, but with an experience. So, what about augmented and mixed reality? So, these are terms that are intermixed, and all they refer to is that there is part of the real world environment preserved, and you can either add information or take information away. So, it's a layering of VR onto the real world, and it can be constructive or it can be destructive, take away destructive. And so, you can see this in anatomy, it's being used for learning anatomy. Google Glasses was a good example of an overlay, and we're using it on mobile devices now for insect phobias, where you can create in your environment the sense of having multiple insects. So, what about the evidence for XR and SMI? So, what exactly do we have proof of how this might be helpful? Well, first, before I do that, I just want to make sure we're on the same page about what serious mental illness is. So, traditionally, the psychotic disorders, bipolar disorder, major depression, mood disorders are considered the most common serious mental illness. But as probably most of us know here, many other disorders, especially anxiety disorders, trauma, eating disorders, and many more can reach the point of being so severe and cause functional impairment. So, really, we're talking about any mental illness or behavioral illness, including chronic pain, that causes severe functioning problems in multiple areas. So, before I dive into each maybe diagnosis, I just wanted to talk about the potential uses in the research so far using XR. So, I kind of put it into four buckets here of ways that it's been used so far in the literature. So, the first and the most studied is exposure. So, you can use it to help people desensitize to things that they're maladaptively sensitized to. You can help people habituate. You could help inoculate against stress and sensitization with stress inoculation. It's been used for distraction, and this can be profoundly helpful in pain. So, Hunter Hoffman did one of the first studies of this and showed decreased use of opiates for people undergoing wound debridement in burns, third-degree burns. It can be used for helping in emotional distress and tolerating that better. So, there is so much real estate in the nervous system devoted to vision that when you can be fully immersed, it often can block other pathways that are coming in. It also can be used to stimulate people in sensory-deprived contexts such as depression when people become behaviorally deactivated or in geriatric settings when people have lost many of their stimulating activities. It can be used for training and enhancing learning as we talked about, especially those procedural types of learning such as mindfulness, diaphragmatic breathing, progressive muscle relaxation, but it can make more fun things like psychoeducation that are more knowledge-based as well. And then lastly, it can be used for research, for standardizing experiences, for measuring things like eye tracking. You can collect measurements as well, avoidance behavior and movement especially. And it's been applied to many common psychiatric disorders including trauma, anxiety, addiction, pain, eating disorders, autism, schizophrenia, mood, not so much. And we'll talk about why coming up. And so, yeah, before we take a deep dive into the specifics, I kind of wanted to give from the meta-analysis looking at all kind of a trans-diagnostic viewpoint, some of the take-homes so far in the literature. So, for most interventions, VR has been shown to, basically not to be inferior. So I think the take home message is that it's not superior, it's not a replacement for non-VR evidence-based psychotherapies, but it should be thought of more of as a enhancement, let's say, it may make that evidence-based treatment more palatable. And so we're really needing more research, not just head-to-head trials of the non-VR based interventions, because I don't see us swapping out this kind of technology for psychotherapy, but more using it as an enhancement. So we really are needing more and are starting to accumulate how it could be used to increase feasibility in more implementation studies. And so you could see that it is very helpful and could be very effective for things that require repetitive intrusive actions or require a substantial cost, like having people do exposures with flying that's very expensive. And I kind of think about it just like, you might get the same outcome if you have surgery with or without pain medications, right? You're still, you know, your broken bone will heal and you'll be able to use your hand eventually, but it's gonna be a lot more comfortable if you have pain medications and anesthesia. So I think we need to be doing more studies looking at how it actually enhances therapy other than replaces. I'm also gonna be talking about my own anecdotal observations running our VR clinic where we've treated these evidence-based, where we have informed evidence, we're using this on those disorders. So I'll tell you a little bit about my anecdotal experiences as well. And one other thing to think about is, yes, it has been able to make that leap to telehealth now, luckily, and I'll tell you how we're doing that as well. And it also allows you to remotely have people practice XR experiences at home and you can track their compliance with it as well. So we'll be talking about that. So I would like to take a deep dive into anxiety disorders, trauma and stress, psychotic disorders, eating disorders and mood disorders and tell you a little bit more detail about those. But of course, the scope of this, there's much more to say. So I am gonna go kind of rapid fire here and I'm glad we're gonna have questions at the end to answer and be able to go more in depth where we're needed. So we'll start with anxiety disorders. So a third of us will experience this in our lifetime. And for some, it is very disabling with social and economic costs. It is the most common mental health disorder and the treatment of choice is psychotherapy. And this does include mostly cognitive behavior therapy with an exposure base for most anxiety disorders has been shown to be the most helpful. So just a little quick primer on what exactly exposure is. So it's based on this idea that anxiety is maintained through ongoing avoidance and safety behaviors. And so maladaptive feedback loops of behavior happen. So this might be a great feedback loop if you are on the Savannah and need to move farther and farther away from a lion's cave, the more afraid you get of this cave, the farther you move away and the more likely that you will survive in your descendants. But this is not gonna be too helpful if you need to work and take an elevator and the more you avoid the elevator, the more you get a frightened by it. And so the way out of this positive feedback loop is by exposure and actually facing the thing that you're afraid of stopping the avoidance and stopping the safety behaviors. And so the more frequently you do this, the more intensely, the more quickly you have a fear extinction response and you get normalization and habituation and the amygdala and some other limbic and prefrontal networks. And there's three types of exposure that we'll talk about. So there's in vivo where you actually face the thing that you're afraid of. And that's the ultimate goal of all these therapies usually. There's imaginal where you think about and imagine the things that you're afraid of. And then there's in virtual where you're using a simulation experience to expose yourself to the feared stimuli. And so most therapy is done gradually. And so some of the ways you might use this for anxiety disorders is you might first start with the person before they're going to in vivo exposure, have them imagine the thing that they're gonna be facing. They're afraid of elevators, they start to talk about and imagine the elevator. And then you can, instead of having the person go right into the in vivo, you could have them do an in virtuo, which is an immersive experience in which they can have that same experience and kind of up the ante. And so they're prepared more for the in vivo. So it can be kind of like a palliative third step, a second step or mediary step when you're doing exposures and make it more comfortable. So what about the research and the evidence? So most of the studies are small and underpowered, but they do seem to show that they're not inferior to non-VR CBT in vivo treatments and that the durability lasts over time. There's some evidence mounting that dropout rates may be lower. So it may be that palliative effect of the VR allows people to stay in or it's more acceptable. There are a few studies of obsessive compulsive disorder or generalized anxiety. So definitely some room there for researchers to get involved. I can't explain why there's a gap there with the OCD. And then the, so in our clinics, we're using mostly YouTube 360 videos, interestingly enough, which are completely free. And because most people's cues in anxiety are very idiosyncratic and there is no platform that's going to have all the content that's possible for people's, the things that people are frightened of. And so YouTube 360 has a huge amount of content and you can also, or you can create your own content as well with a movie and turn it into a 360 experience. So we've been doing a lot of that. We also use a platform called Sias that has been able to make that leap to telehealth because most where we are in ambulatory care, we're strictly still telehealth and looks like we're gonna stay that way since COVID for quite a while. And this platform is about $1,000 a year currently, but there are other platforms, although from my knowledge, none of them have the ability to do telehealth yet. So there's InVirtuo, that is actually an immersive embodied experiences, virtually better behave VR. And so we chose the Sias because it has most of the evidence-based treatments for anxiety, with the protocols and the source citations when you need it and some psychoeducation for the patient. So that's been very helpful. And it's sort of a turnkey psychotherapy platform. You can be up and running if you're trained in CBT, it'll probably be quite helpful. And you can see this as some of the content that is sometimes used where you can increase the difficulty, for example, with social anxiety, giving speeches, and you can increase the difficulty to medium with friendly faces, then you go to neutral faces, or you can go to hostile faces. And so you can, it's nice, you have some movement and you can control the stimuli and make it more and more challenging. So trauma related disorders. So one to 6% of the population around the world prevalence, and we know that this is a high risk of suicide and mortality and morbidity. And the first line treatment is psychotherapy. So we've got three currently evidence-based treatments that are known, which are prolonged exposure, cognitive processing therapy and EMDR. But they're not perfect. There's attrition rates and up to 22% for PE and 18% for EMDR. So not everybody can tolerate them. And there are large response rates, anywhere from 40 to 75%. So definitely room for enhancement of these evidence-based therapies. And there have been quite a few randomized control trials and even seven that compared the VR prolonged exposure to regular prolonged exposure. And they were found to have no significant difference between the two. Although on follow-up, there's one study that did show that they may not have the same durability over time, which was disappointing for the VR enthusiasts, that the traditional prolonged exposure may be superior in durability. But I also wanna mention that these studies were mostly in the military populations. And they actually just used VR And they actually just used VR in the imaginal component of the treatment. And for those of you that do prolonged exposure, you'll probably know that there's two types of exposure in prolonged exposure. You have the imaginal exposure where the person remembers the past events. And then you have the in vivo exposures where you're getting people to expose themselves to what they're avoiding because of the past. And so in our clinics, we're really using this to enhance the in vivo exposure. So if somebody's afraid of taking the bus because of trauma, we'll have them first do a simulation in VR and to help the in vivo exposure be more comfortable. And none of these studies used VR in that way. And there are also some EMDR-based randomized control trials showing a lot of promise. And actually SIAS does have an EMDR component. I'm not trained in EMDR, so I haven't done it yet. I'm looking to do that one of these days. And also to prepare people for PE, in most protocols you have people learn a diaphragmatic breathing or aggressive muscle relaxation. So you can also teach that skill in VR. And like I said, we use the 360 videos often to help people with their in vivo exposures. All right, so even more exciting is the in the realm of psychotic disorders. So these we know are devastating illnesses and one of the top 10 contributing to global burden of disease according to the World Health Organization. And although antipsychotic medications is the mainstay, we know that enhancements and outcomes occur when you add cognitive behavior therapy, social skills training and cognitive enhancement therapy for executive functioning. So the first two have been explored with the use of VR. With showing some maybe even superior results compared to their non-VR components. So it's one of the few disorders that are showing maybe the VR component may be superior to its non-VR component. So it started in 2011. The Park and colleagues showed that VR with social skills training seemed to be superior to the non-VR social skills training, especially in regards to the verbal communication. Then this was explored further with Freeman and his group in 2016. And I really liked their model because they used VR just to enhance CBT. So using it as an enhancement rather than just a replacement and they improved persecutory delusions compared to just VR exposure alone. So they were kind of showing that the enhancement of VR with existing evidence-based treatment was better than just doing VR by itself. And they really focused on using CBT to help people with behaviors such as dropping safety behaviors. For example, being able to look somebody in the face and in the eyes and not avoid that. And then more recently that 2018, a very large study showed therapists guided CBT with VR help patients much more than a non-VR control significantly improved anxiety, paranoia and safety behaviors. So very exciting evidence developing here. And the platform that we use, it does have some of these protocols in there based on these studies using a bar, metro, an elevator and mood disorders. So there's not so much research here or randomized control trials, even though this is quite an impactful illness that we definitely need enhancements in treatment. The standards are CBT, mindfulness, relaxation, behavioral activation are all evidence-based treatments. And some of those components of the evidence-based treatments can be delivered in VR such as mindfulness and relaxation techniques and interpersonal skills training. One of my favorite students and a graduate student recently completed a pilot study of using VR to deliver behavioral activation. And she had three armed pilots RCT in which they compared VR, VA, behavioral activation to regular behavioral activation and to just treatment as usual. And although it was very underpowered for statistical significance and efficacy, we were able to document feasibility and acceptability and tolerability. And there was some signal that this may be helpful in that we had some clinical significant changes in the PHQ-9 and the VR group. So hopefully we'll be able to pursue that more. I think behavioral activation definitely is an area that VR could be leveraged to enhance the existing treatments. So then moving on quickly to eating disorders. We know there haven't been any randomized clinical trials of a VR intervention, but a lot of deep dives into enhancing existing treatment protocols using VR for established techniques such as QD desensitization, that's normalizing impulses towards food because there's people either need more impulse control or they need to stop avoiding food. So QD desensitization is used. Body distortions and helping people to more accurately perceive their body size as well as helping people to improve their body satisfaction. And so again, we have some science protocols that help in doing QD desensitization and accurate body prediction and size. And so the other thing I wanna talk about is cybersickness before we move on. So cybersickness is very similar to any other kind of motion sickness or what's called simulator sickness. And right now we don't know the real incident and prevalence of this because there's been so much change in devices and technology. But if you go back to 1999, where it was documented for the early VR, it's about one to 5%. So it does happen. And for providers who are kind of worried about this, there are some standards that can minimize this happening. My favorite and the principle I kind of use is that you want to preserve the autonomy of the person. So the more that they can interact and have a sense of agency in the environment, the less likely they are to develop it. So standing, moving, being able to change their focal point, and not restricting head movements, that can really empower people and prevent this. You also wanna give psychoeducation and things like a dry mouth, maybe an indicator of oncoming simulator sickness. You can have questionnaires that are standardized forms. And you also wanna make sure that you're monitoring and probably have people have under 20-minute experiences just to be safe. We're not sure what the mechanism is. There may be a mismatch between the vestibular and visual systems, but there is evidence that there's a psychosomatic component as well. But I did a study of many. We did almost 30 patients with somatic symptom disorder who have central sensitization and I thought that they would suffer a lot with cyber sickness and actually none of them developed it and they were in very immersive embodied experiences, so I was surprised. I have not had too many people at all have cyber sickness, but there are barriers in the literature that have been documented, so the cost, I'm sorry, I'm having trouble with the arrows here. The cost as well as perceived and real technological difficulties both by patients and providers may be an issue. Designing without clinical input, the design being done currently is not patient-centered or provider-centered. There is side effects that are real cyber sickness. I guess they don't want us for some reason, the slideshow doesn't want me to stay on that slide, so I guess I'll just move on. But there are barriers and we can talk about more of those as well. Some of them are often just attitudes and perceptions. One of the reasons we're getting this webinar is to help people move past those barriers. What about you if you want to start applying this into practice or organizations, how exactly would you do that and take a deeper dive and acquire the skills to do that? Unfortunately, right now, there aren't any standardized certifications or oversight or adherence criteria. I'm hoping that will change over time and reason why more and more of us need to start to get involved so that we can create some best practices. Right now, there's through professional workshops, there's often most conferences will have one or two workshops. The American Psychological Association has two workshops coming up with Elizabeth McMahon. She will be doing one in November and December. The Association of Behavior and Cognitive Therapy often has workshops. You can look for software companies as well. They often will have training in their package. But again, they're not third-party evaluated, so we can't say anything about their certification process, but many of these companies do have certifications available. I know in PESC, Elizabeth McMahon does have a DVD and webinar that's available online. There's the source if you wanted to find it. Just this month, Elizabeth McMahon's book came out that's available on Amazon and other sites for virtual reality therapy for anxiety. That's the first clinically useful, really focused on the application of it in incorporating it to enhance psychotherapy. The other books that are available by Springer, they're good if you want to take a deep dive into the evidence-based and the development and the principles involved, but they're not as clinically useful in really the application and the skills acquisition part of that. Luckily, Elizabeth McMahon lived near me in the San Francisco area, so I was able before COVID to go and get some supervision. With her, and I've used her as a mentor. Just like many other types of orientations of therapy, we use colleagues and we use mentorship and supervision. I would encourage you as well to find a supervisor and a mentor. This is a wonderful site that's free of charge, there's no commercial interest, the VRtherapistinternational.com, where you could find therapists that might be willing to do supervision. Then I would really just encourage you just to jump in and be an early adopter there. At this point, we have very few experts and try it out. Maybe even start with just if you're doing an exposure with a patient, you could experiment with doing a YouTube video of the stimulus and seeing if that might make it more palatable for the patient and use some Google Cardboards in your office, or the patient might have a pair. But I would say one of the things is you just got to jump in and try it. The potential for actual possibilities for the future. Well, one thing I want to bring up is the past when thinking about the future, is that it was only the 1990s where we first used a very crude version of virtual reality, which is called mirror therapy. Ramachandran showed that it could actually amputate phantom limb by using a perceptual illusion. That was our first look at how neuroplasticity and the visual system that we could harness this to make changes in the nervous system. Because of our homuncular flexibility and using tools, that movement and sensation are intimately linked. I think that we're going to have a lot more uses, especially for chronic pain and to break these patterns of these disuse syndromes. Often, if the visual system sees no movement, it alarms the nervous system and will send more pain signals. That makes evolutionary sense because if you can't move something, it's probably not a good sign and you need to move less. But you can get into these patterns where this is maladaptive. Being able to see movement can often change sensation. We even know that the neuroplasticity has been documented with this increased excitability and the ipsilateral primary motor cortex, which really, I think, shows that perceptual illusions can change the nervous system. We need to harness this, especially in body transfer illusions. We've done this and are exploring this in my office with mirror therapy. On the HTC Vive, we created a mirror therapy and are working with people with motor and sensory symptoms that are just on one side of their body. Having remarkable results with people's dystonias getting improved and chronic pain syndromes improving. Then the other, I think, really exciting area is this implicit biased and reprogramming of stereotype threats that can be internal or external. Jeremy Balanson was one of the first to talk about this proteus effect, where people who inhabit an avatar and have embodied experience of an avatar with certain characteristics, will change their beliefs about those characteristics and actually alter their behaviors after. After having a superhero experience, people have been documented to be more helpful after the experience. Also, implicit stereotypes and racist beliefs have been shown to be able to be changed through these types of experiences. Organizations are leveraging this right now with VR for empathy training and diversity training. We know that it's very hard to change these implicit beliefs actively. Even the most motivated person in CBT wants to change a belief, sometimes can't. That you having these experiences may help people be able to better do this and not in a passive way and an implicit level changing their stereotypes. Then the other really exciting area is in body image. We know that many disorders involve alterations in one's body image. Very simplistic terms about how we understand how people form their body image is you have this top-down allocentric viewpoint of your body, what others think about your body, what you look like to other people, to your culture. There's these beliefs that are top-down, these allocentric point of view. We mix this with our egocentric point of view and sensations. For some people, they're not able to override that allocentric point of view. For example, if someone called them fat or they were overweight at some point, even if their body changed and they're at a normal BMI, they can't let go of that feeling of being overweight, even if they've lost weight. Body swapping illusions are looking to be very helpful in allowing these model updates of people's body images. I think when the brain sees discrepancies, it modulates and it changes models and it helps with new learning. It looks like we're going to be able to do some really great things with body image and body distortions. Co-creation by patient and provider, I think, of avatars and experiences are really going to be useful in reprogramming of internal biases. Then the last part, for telehealth, I think we're going to be seeing platforms that involve immersive technologies, Holoportation. The Holodeck from Star Trek is coming. It's the videographic representations of ourselves in environments where we're going to be able to meet, and that's happening right now. People are able to meet in virtual spaces together in an immersive 3D and six degree of freedom environments. We can use that for provider and patient interactions, and maybe it'll replace Zoom meetings. We can do group therapy and consultations. This platform, Mark Zuckerberg, right when I was finishing these slides, came out with touting this Horizon Workroom. That's just an example of what's coming down the line. Here's some references if you really want to take a deeper dive. Please feel free to contact me as well. Here's some of my sites and that's it for now. I'll go ahead and turn it over to questions. Thank you so much for such an interesting presentation, Dr. Bullock. Before we switch to question and answer, I want to take a moment and let everyone know that SMI Advisor is accessible from a mobile device, not yet a virtual reality device or extended reality, but you can use the SMI Advisor app to access resources, education, upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. You can download the app now at smiadvisor.org. We'll jump into question and answer and get through as many as we can. One here says, can you say a little bit more about reductions in symptoms that you've seen in people with psychosis spectrum illnesses? Yes. Unfortunately for my experience, I have seen very few psychosis patients myself because we have the Inspire Clinic. We have a dedicated clinic where Kate Hardy actually does CBT and is exploring the VR. I can't tell you about my anecdotal experiences if you're asking about that. But the research and the reports that I'm hearing is that people are having much better chances of getting jobs and functioning and earning a living, so that the vocational improvements seem to be quite high. Is that what you're asking? That's it. I've seen that too, especially helping with some of the negative symptoms of psychosis and helping people develop more social skills. VR seems to be useful for us. Exactly. I think helping actually with functional outcomes, which is terrific, can perhaps mediate through negative symptoms. But I think we're still learning. Different question says, how do you introduce or bring up VR to a person? How do you even open up the topic and say, have you tried VR? What about VR? Oh, yeah. Well, luckily, we kind of have a filter in our intake because a lot of people have heard about my clinic, so they come in begging for VR. So I don't usually have to actually introduce it. Although in my neurobehavioral clinic, where I do most neuropsychiatry, sometimes I'll bring it up. People won't even know I'm doing VR and I might mention it and give them some of the research evidence and give them some psychoeducation about how it's been useful. So I might bring it up that way and really collaboratively make that decision about whether they think it would be useful or not. And some people are just like completely phobic and are like, oh, no, I think I would get dizzy if I did that. There's no way I would do that. So I wouldn't force it on anybody. And you might need to do some motivational interviewing as well if someone wasn't ready for it. So it's a collaborative decision. That makes sense. And this question is, are there billing codes or ways that you support this? Or is it more kind of we're not at the billing stage yet for using VR as part of care and SMI? Yes, so not that I know of. There are no codes that you can add to enhance your revenue because of this. But I will say there probably are more indirect savings, you know, when I as far as efficiencies in practice. So if I'm giving progressive muscle relaxation in VR to somebody, I can finish my note and I could probably see another patient for the day. So there may be efficiencies in scale or that come with it. You may be able to market. It might be a marketing issue if for private practitioners, if you're a VR provider and people. There's kind of this branding that goes along with VR that you must be doing something special or it might decrease stigma to think about technology being used for mental health. And you may be able to attract more patients in that way if that's what you need. But as far as I know, there's no codes, procedural code that you can add. As we know, changes in regulation, if there's not a code this year, it may, things are changing very rapidly in the technology mental health world. I'll see if I can put in this last question. This question says, how does the creation of the video being used work? Say, I'm sorry, say that again. How does the creation of the video being used work? Yes, so, well, ideally, if you have a nice six degree of freedom or a VR camera, so you can buy VR cameras and take a video and then publish it on YouTube or use whatever software you have and then create a VR video. Or you can also just take a regular video and be able to watch it in a YouTube 360 modality. They have this little cardboard icon when you publish on YouTube that turns it into a VR experience. Got it. Is that what you're asking? Or companies also create, you can have companies create experiences for you as well. Got it. So I think I said, I'll actually advance this to the next slide because I know we've done so much. And if you have any follow-up questions on this or any other topic, I said we have our team of SMI advisor experts who are available for online consultations. Any mental health clinician can submit a question and receive a response from one of our experts. The consults are always free and confidential. And we'll jump to the next slide. So SMI Advisor is proud to partner with the APA and the Mental Health Service Administration, SAMHSA, for the conference that will take place October 14th through 15th. The Mental Health Service Conference keynote address will be from Dr. Marion Delton-Ritton, the newly appointed Assistant Secretary for Mental Health and Substance Use for HHS-SAMHSA. The conference agenda will feature topics such as climate change in mental health, sociopolitical determinants, structural racism, mental health in rural and indigenous populations, and much more. I encourage you to learn more and register right now at psychiatry.org slash MHSC for Mental Health Service Conference. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification for attendance can take up to five minutes. And you'll then be able to select next to advance and complete the program evaluation before claiming your credit. And please join us next week on Wednesday, September 29th, as Rob Cotes, Donna Rowland, Jonathan Meyer, and Ray Love present Keeping Up with Clozapine Rams, a Guide to the November 15th Changes. We'll present Keeping Up with Clozapine Rams, a Guide to November 15th Changes. November 15th is coming up soon. Again, this free webinar will be available on the 29th from 3 to 4 p.m. EST. Thank you for joining us. Until next time, take care.

XR technology

virtual reality

anxiety disorders

trauma-related disorders

psychotic disorders

eating disorders

mood disorders

exposure therapy

PTSD

cognitive-behavioral therapy