Virtual reality technology usage increases as cost, connectivity, quality are improved.

If you haven’t thought about virtual reality as a mental health treatment option, that’s OK.

Often, it’s not until people slip on a headset to enter a vast and undiscovered world for the first time that they understand its potential.

“Most people are excited to try it because it’s novel,” says Aaron Gani, who left Humana as chief technology officer in early May to focus full-time on his virtual reality start-up BehaVR.

“The most common response afterward is not how cool it was but, ‘Wow, that was powerful.’ They have a profound reaction about how powerful it felt.”

There’s an avid group of VR evangelists who want to equip clinicians with headsets so that they can send patients home with them in an effort to treat, or perhaps prevent, the root causes of substance abuse or behavior-driven conditions.

The technology existed for decades but cost, connectivity and the quality of technology were stumbling blocks. It wasn’t smooth enough to be immersive — which is necessary for treatment — and the equipment was too costly to be mainstream.

Then Oculus Rift hit the market in 2016 and VR technology broke into the commercial psyche.

“The closest we’ve had [as a comparison] is dreaming,” says Lee Kebler, president of BlackBox Realities, a Nashville-based virtual reality development company.

Now, people who enter the virtual world are greeted with vibrant color and realistic depth that almost instantly mutes the physical world.

From the physical world to one built by code

Noah Robinson, a clinical psychology graduate student at Vanderbilt University, is using virtual reality to treat people who are admitted to JourneyPure At The River in Murfreesboro for substance abuse and addiction.

“Someone can leave the rehab center and feel like they are in a forest, on the moon or in a concert hall,” Robinson says.

Over the summer, Robinson will record the results of a two-semester study he and a cohort of undergraduate students conducted. Anecdotally, results indicate that people who use VR feel lasting impacts in the hours after undergoing a 30-minute stint in a headset.

Robinson — whom both Gani and Kebler immediately identified as a go-to expert to talk about VR for treatment — knew he wanted to incorporate the technology into his studies before he arrived at Vanderbilt.

Now, he’s the “man in Middle Tennessee, maybe in the U.S.,” Kebler says of Robinson.

It’s easy to get swept up in the virtual world — giggling at the quirkiness of the tutorial or gently flinching in exploration. Kebler says executives who want to work with BlackBox revert to their inner 4-year-old when they try Tilt Brush, a 3D painting app Google developed.

In fact, it was the reaction of a woman who had been on suicide watch to the mere introduction portion of the HTC virtual experience and a game that confirmed Robinson was on an interesting, and meaningful, path.

Robinson offhandedly asked if the woman wanted to try VR after she had talked about her anxiety and some serious trauma. She’d been withdrawn and he hoped it would be a distraction for her.

She started laughing and smiling almost immediately upon entering the virtual world.

“There’s a lot going on in someone’s mind when they are in that situation,” Robinson says. “There was this transformation that was really powerful. That’s what I spent the last semester exploring.”

A remaining, and vast, area of inquiry is how the brain processes virtual reality — and what it means to escape from the physical world to one built by code.

Kebler’s BlackBox won’t yield anything violent — unless it’s a training program that’s not going to be disseminated.

In earlier generations of VR, the user had to have “a very open imagination” to get lost in the technology because it wasn’t immersive — the person couldn’t get into what’s called being “immersed in a state of flow.”

“We don’t really know how our brain interprets VR,” Kebler says. “‘I was in my office scuba diving’ — that’s not a sentence, but it is now.”

Chris Gonzalez, director of the marriage and family therapy program at Lipscomb University, is curious about the possibilities. Technology isn’t a part of his practice — yet — but he has seen it at conferences and imagines potential for its use.

“I really feel two ways about it,” Gonzalez says. “On the one hand, it’s kind of outsourcing the work and I’m wondering if the work gets done inside the person. But then, on the other hand, you can do things you might be afraid of or can’t do by yourself. You may be doing it internally through the character by externalizing a part of yourself, to possibly be more experimental or take a risk you might not take.”

He thinks clinicians are waiting for research.

There is research on VR for exposure therapy to treat post-traumatic stress disorder, distraction-based treatment for pain and education and skill measurement that was published in the late 1990s by Max North, Sarah North, Joseph Coble and Ralph Lamson, among others.

The technology wasn’t practical at the time but it worked, Gani says.

“Folks who are in the health care business are smart to be cautious caring for patients,” Gani says.

Robinson wants to target the neural circuits to retrain the brain.

“I want to prove that it works,” he says.

‘Not like buying an MRI machine for $1 million’

The cost of virtual reality headsets is plummeting.

Just two days before Gani left Humana, the Oculus Go hit the market for $200. It’s a lightweight headset not much larger than an iPhone and the speakers are disguised in the headband.
The HTC Vive headset is $499 although it needs to be connected to a computer that runs Windows. The fit is unobtrusive and the imagery is astonishingly crisp and seemingly tangible for something that could stow in a carry-on.
Right now, Robinson is using the HTC and thinks it’s the best for therapy. But he picked up the Oculus Go soon after it released and talked about its potential.

Robinson envisions a day when people are, perhaps, released earlier than otherwise from rehab and given a headset to take home to extend the connection to therapies and craving control approaches learned from treatment. The price of a headset, depending on the model and other necessary equipment, is either roughly the cost of one day in rehab — or less.

Cost and the lack of reimbursement aren’t issues for the clients working with BehaVR. Insurance companies aren’t yet paying for treatment, but that treatment is being used in clinics to improve patient satisfaction and engagement — which means patients stick around the program, Gani says.

The gear, which can be bought at Best Buy, isn’t the hurdle for clinicians because “it’s not like buying an MRI machine for $1 million,” Gonzalez says. He thinks clinicians are simply waiting for some research before it’s widely implemented.

“The new generation of technology appeared so quickly the world has yet to fully grasp what’s available,” Kebler says.

A future of multiple applications

Patients could find themselves wearing headsets to treat a variety of problems with roots in behavior.

BehaVR is in the market with a smoking cessation program and is weeks away from debuting a chronic pain program that will be used in physical therapy and surgery centers.

Down the road, Gani plans to work with several addiction recovery programs and projects that his company will have programs to help with weight management and obesity.

“Our goal is to address the holy grail of health care — behavior change. What’s at the core of many of those problems is emotional regulation,” Gani says.

Gonzalez and Robinson both anticipate a time when group therapy is held without the participants being in the same room.

Sometimes, Gonzalez says, it’s hard to get family members in the same room at the same time — maybe a relative who needs to be involved in a conversation lives in another state or a parent has a business trip. VR could put them together no matter where they are.

The design of the treatment and programs will be important.

The existence of a virtual world redefines “what’s real” because what the person recalls is just like an event in the physical world.

Kebler talks about designing with intention and the acknowledgement that questions remain. For some people, the escape could be almost a replacing of one vice for another. Or it could be the idea that what the person does in VR is about her or him and not the technology.

“You start replacing people’s realities and, of course, there’s an addiction factor but there’s also the ability to be improved people,” Kebler says.

Robinson thinks it’s key to make sure the patient using VR is closely tied into a treatment program — and not using the technology independently to escape from a depressing, sad or upsetting reality.

“People use drugs to make everything go away — for a relief of negative emotions,” said Robinson. “It’s potentially the same use as drugs (but a) completely fictional world, which is complex and separate from the real world. They are tuning out their anxieties and get relief.”

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