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A Primer on Virtual Reality Exposure Therapy (VRET)

Imagine riding an all-glass elevator to the top of a tall skyscraper, exiting to a narrow bridge projecting off the roof, and then looking down. Such a journey might evoke some level of discomfort in most of us, and for a subset of 3-5% of Americans with acrophobia, it would trigger marked to debilitating anxiety. I completed this very exercise, only without ever leaving the comfort of a conference room, during a product presentation by Psious for its virtual reality therapy platform.

The Role of Presence in Virtual Reality

Effective VR therapy depends on the experience of presence in a virtual environment. Lombard and Ditton suggest that telepresence creates an illusion of nonmediation whereby a person “…fails to perceive or acknowledge the existence of a medium in his/her communication environment and responds as…if the medium were not there.” This illusion may suggest to participants they are receiving all information cues relevant to an interaction, when in fact they are not.

Hodges, Rothbaum, Kooper et. al. present a conception of presence based on three primary determinates. The first, fidelity and extent of sensory information, corresponds to the quality and quantity of information available to a person experiencing an environment. The second, consequences of a participant’s actions, corresponds to the interaction between a participant and the environment. That is, in addition to the participant’s ability to modify his point of view through head movement, or to interact with objects in the environment, consequences would also include physical laws. For instance, if the user stepped off of a platform, gravity would pull the user down, or, if the user collided with a solid surface, the user would experience pain. The third, gestalt of the participant, represents what the participant brings to the environment. Or put another way, a person’s reaction to his or her environment depends on the whole of who he or she is, in addition to his or her previous experiences.

A primary difference between the experience of an event in a virtual environment and a real one lies in the intensity or vigor of the experience. A virtual environment generates fewer consequences for a participant’s actions in terms of the second determinant outlined above. Further, familiarity with a virtual environment does not in itself increase the participant’s sense of presence, and a person’s perceptions of real-world situations and behavior may change based on his experiences within a virtual world. However, a person’s experience of a situation in a virtual environment may evoke the same reactions and emotions as the experience of a similar real-world situation, even when the virtual environment does not completely represent the real-world situation.

Psious, One of a Few Platforms on the Market

Psious’ platform is similar to a few others on the market. The simulation is delivered through a VR headset, in Psious’ case the Gear VR by Samsung. Software simulations are developed by an in-house team for an array of possible phobias that range from fear of heights, fear of driving, fear of animals, agoraphobia, claustrophobia, and fear of public.

In the fear of heights simulation, for example, a patient rides an all-glass elevator outside a tall building to a narrow bridge skywalk that overlooks the city, during which the therapist can modulate the behavior and function of the elevator. In the fear of public simulation, a patient faces an audience in a large hall to deliver a speech amidst a number of distractions, including audience feedback. In every case, a therapist guides the patient through the simulation and exercises discretion over its level of intensity in a progressive, hierarchical fashion matched to the need of the clinical approach.

I found my trial simulation immersive to a considerable extent, even though I was in a room full of talking people. The graphics fell short of photorealism, but the program’s frame rate was smooth, comparable to anything one might stream on TV. On two rare occasions, a loaded scenario froze, but otherwise, all simulations ran smooth, without issue. In a controlled environment, free from people and distractions, I could see my level of immersion being far higher. For another audience member who volunteered, the same simulation delivered significant levels of anxiety, as evident from her verbalizations and physical movements.

Psious operates on a trial-before-commit subscription model. For $99, users can join its Expert Network and receive shipped gear, which includes a Samsung Gear VR headset for trial, after which a user can elect to extend membership. Membership includes access to instructional online video and written materials that describe the functionality and treatment protocols on the integration of virtual reality resources, as well as a training and Q&A session with one of Psious’ staff psychologists.

VRET in the Current Telemental Health Landscape

Relative to computerized CBT (cCBT), internet-mediated CBT (iCBT), and mobile therapty (mTherapy), VR exposure therapy (VRET) is a younger technology platform, which has received less research attention than cCBT or iCBT, but data suggests the technology carries a potential role in the treatment of several psychiatric conditions, including phobias, PTSD, OCD, and substance use disorders. VRET may also possess advantages over conventional forms of therapy when it comes to recreating challenging exposure situations, in addition to the advantage of additional control over the exposure exercise and a sense of increased safety to the patient when confronting phobic stimuli. Exposure therapy is the biggest application for VR technology at present.

VRET vs. Conventional Therapy

Dr. Albert “Skip” Rizzo, Director at the University of Southern California’s Institute for Creative Technologies and an authority on the design, development and evaluation of VR therapy systems, thinks VR therapy presents a number of benefits over conventional therapy, including reduced psychological barriers to treatment, since patients can participate from the comfort of their homes. In addition, he thinks the very medium of VR carries added appeal to a generation that has grown up on video games, such that otherwise averse patients may get through the door to treatment.

The U.S. military has invested heavily in VR in response to veterans who served in Operation Iraqi Freedom and returned with high incidences of PTSD. In fact, Dr. Rizzo’s lab has built a virtual Iraq and Afghanistan simulation, which can simulate the smell of diesel, rotting garbage, and burning rubber. According to Rizzo, much of the technology driven by the military can translate to the civilian world. Other advantages of VR therapy include the ability to access patients in remote areas and considerable cost savings when compared to in vivo therapy.

Perhaps three main weaknesses of existing applications of VRET include the upper threshold of graphical realism, the fact that certain conditions still necessitate face-to-face contact, and the lack of clinical research data on VRET relative to other forms of CBT. When it comes to graphical realism, a specific challenge of medical VR is to convey finely-detailed 3D structures with real-time interactivity.

Open Questions

There are a few open questions about how VR therapy could operate alongside cCBT, iCBT, or mTherapy in a patient treatment program. To what extent is VRET complimentary to the above approaches? How might psychiatric care be optimized or compromised through application of VRET alongside other forms of CBT, including traditional CBT? The answers to these questions, in addition to further study on VRET, would advance our understanding of telemental health in an important way.

What the Affordable Care Act Means for Mental Healthcare

The U.S. government for decades has struggled to devise programs that integrate needed services for people with severe mental illnesses. Implementation has been limited by inadequacies in the behavioral health policy framework, poorly designed payment approaches, and dysfunctional regulations. Fortunately, the Affordable Care Act has brought a number of policy changes that improve access to mental and behavioral health services for millions of Americans.

Expansion in Insurance Coverage

The proliferation of health insurance coverage through the Health Insurance Exchanges (HIE) and state-specific Medicaid dramatically expands coverage for those not eligible for Medicare. The ACA also prohibits insurance companies from denial of coverage to individuals with pre-existing conditions. This is significant because mental health disorders were among the most common pre-existing conditions triggering health insurance denials before the full implementation of the ACA.

Improved Mental Health Coverage and Funds for Behavioral Health Treatment

Through the expansion of the Mental Health Parity and Addiction Equity Act (MHPAE) of 2008, mental health and substance use treatment is now one of the ten “essential health benefits” for all health insurance plans in the individual and employer market, inside and outside HIEs. Insurance plans must now treat physical and mental illness with parity when considering necessity for medical treatment.

Second, the Medicare Improvements for Patients and Providers Act (MIPPA) ends the discriminatory mental health coverage that required patients pay up to 50 percent of the cost of approved services, in contrast to the 20 percent copayment applied to other types of outpatient services. 100 percent parity now applies in copayments for outpatient service; thus, Medicare will now cover 80 percent of the cost of mental health outpatient services, consistent with other types of outpatient services.

Third, ACA establishes the Community Health Center Fund, which provides $11 billion to expand services offered in Community Health Centers and to construct additional sites, including those for behavioral health treatment. These funds can potentially enable access to mental health treatment in rural areas where such services are often scarce.

What this Means

The dramatic expansion in insurance coverage for American and improved mental health coverage and allotment of funds for behavioral health treatment in rural settings means more funds are now accessible for the delivery mental and behavioral health services in the U.S.–healthcare tech companies in this space stand to benefit from the new opportunities in reimbursement.

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