Virtual Reality as a Moderator of Psychedelic-Assisted Psychotherapy

This paper (2022) makes the case for using virtual reality (VR) as a full-spectrum tool able to capitalize on and catalyze the innately therapeutic aspects of the psychedelic experience, such as detachment from familiar reality, alteration of self-experience, augmentation of sensory perception and induction of mystical-type experiences. This is on the basis of VR’s evidenced capacity to: aid relaxation and reduce anxiety; buffer from external stimuli; promote a mindful presence; train the mind to achieve altered states of consciousness (ASC); evoke mystical states; enhance therapeutic alliance and encourage self-efficacy.

Abstract

“Psychotherapy with the use of psychedelic substances, including psilocybin, lysergic acid diethylamide (LSD), ketamine, and 3,4-methylenedioxymethamphetamine (MDMA), has demonstrated promise in the treatment of post-traumatic stress disorder (PTSD), anxiety, addiction, and treatment-resistant depression. Psychedelic-assisted psychotherapy (PP) represents a unique psychopharmacological model that leverages the profound effects of the psychedelic experience. That experience is characterized by strong dependency on two key factors: participant mindset and the therapeutic environment. As such, therapeutic models that utilize psychedelics reflect the need for careful design that promotes an open, flexible, trusting mindset and a supportive setting. To meet this need, the PP model is increasingly supplemented by auxiliary methods, including meditation, relaxation, visualization or spiritual practices. We suggest virtual reality (VR) as a full-spectrum tool able to capitalize on and catalyze the innately therapeutic aspects of the psychedelic experience, such as detachment from familiar reality, alteration of self-experience, augmentation of sensory perception and induction of mystical-type experiences. This is facilitated by VR’s evidenced capacity to: aid relaxation and reduce anxiety; buffer from external stimuli; promote a mindful presence; train the mind to achieve altered states of consciousness (ASC); evoke mystical states; enhance therapeutic alliance and encourage self-efficacy. While these unique VR features appear promising, VR’s potential role in PP remains speculative due to the lack of empirical evidence on the combined use of VR and PP. Given the increased commercial interest in this synergy, there is an urgent need to evaluate this approach. We suggest specific VR models and their role within PP protocols to inspire future direction in scientific research and provide a list of potential disadvantages, side effects and limitations that need to be carefully considered. These include sensory overstimulation, cyber-sickness, triggering memories of past traumatic events as well as distracting from the inner experience or strongly influencing its contents. A balanced, evidence-based approach may provide continuity across all phases of treatment, support transition into and out of an ASC, deepen acute ASC experiences including mystical states and enrich the psychotherapeutic process of integration. We conclude that the potential application of VR in modulating psychedelic-assisted psychotherapy demands further exploration and an evidence-based approach to both design and implementation.”

Authors: Agnieska D. Sekula, Luke Downey & Prashanth Puspanathan

Summary

Treatment Using Psychedelics

Psychedelics, such as psilocybin, DMT, and LSD, have a long history of medicinal use, and have been examined as aids to psychotherapy in the treatment of post-traumatic stress disorder, treatment-resistant depression, and substance dependence.

The impact of psychedelics upon mental health and well-being is thought to be influenced by the phenomenological features of the psychedelic experience, in particular peak or mystical states, and the participant’s individual predispositions.

Limitations of Psychedelic-Assisted Psychotherapy

Psychedelic-Assisted Psychotherapy (PP) studies are yet to systematically evaluate the role of context. However, personal consumption and psychedelic retreats favor nature-immersion models, in contrast to clinical settings in use today, which impede a fluid transition throughout PP.

Trials, preparation and integration phases may be based on diverse psycho-therapeutic frameworks, and may involve the involvement of different therapists or different environments. Moreover, profound psychedelic experiences present challenges for the process of integration, due to their ineffable nature, impaired perception of time, overwhelming emotions and impaired recall.

The lack of congruence throughout treatment could be a causative factor in reported psychological side effects and waning of positive outcomes of PP. A more unified structure could minimize psychological side effects and sustain positive outcomes for longer.

Virtual Reality Therapy

The psychedelic state is characterized by a non-ordinary experience of consciousness, and can be evoked physically, psychologically, or through sensory stimulation. Virtual Reality (VR) can be used to simulate visual hallucinatory experiences, and has found application in the treatment of mood disorders.

Virtual reality experiences have been shown to improve the quality of life for patients undergoing various forms of psychotherapy, including exposure therapy, acute stress relief, pain reduction, and combination therapy with other pharmaceuticals.

A composite approach to therapy combining VR and psychedelics has recently been suggested. This paper discusses the unique features of VR and their functional relationship with psychedelics, and explores the range of synergistic outcomes that could be expected from simultaneous application of VR therapy and PP.

Relaxation

Relaxation methods are frequently used in the treatment of affective disorders, such as PTSD, obsessive-compulsive disorder, and addiction. They have been observed to increase patients’ willingness to continue treatment.

A relaxed mindset before and during psychedelic treatment is one of the main predictors of positive self-dissolution, underscoring the need for more reliable relaxation methods.

A meta-analysis of VR relaxation interventions showed that VR can be used to promote a state of relaxation prior to psychedelic exposure, and to relieve stress acutely if it arises during the session.

Buffering

VR can be used to treat mental health conditions due to its ability to act as an “immersive distractor”. Its therapeutic utility is equally dependent on its ability to subtract sensory stimulation.

Although blindfolds allow limited control over environmental stimuli, current approaches to setting design have not seen major innovation since the earliest psychedelic trials.

VR can be used to reduce distraction from the real world by replacing familiar cues with unfamiliar, fantastical objects and symbols, and facilitating deep immersion into the psychedelic experience.

Mindful Presence

The intensity of the psychedelic experience can sometimes prove difficult for patients, but staying engaged and surrendering to the experience seems to have a beneficial impact on therapeutic outcomes.

Mindfulness meditation is a technique that aims to expand the sense of awareness of diverse physiological and psychological sensations, and has been shown to improve psycho-social functioning when used in combination with psilocybin.

VR-based meditation interventions lead to a deep state of mindfulness, which is reflected in changes of EEG patterns indicative of a relaxed, meditative state. This makes VR mindfulness sessions suitable for all types of therapeutic environments that employ psychedelic substances.

Augmenting Peak States

Approaching the psychedelic experience with a relaxed, mindful mindset is conducive to producing a mystical experience, which is one of the key predictors of positive outcomes following psychedelic psychotherapy.

Highly immersive VR experiences can also demonstrate some of those same, unique characteristics, such as the loss of sense of space, time and even connection to one’s body. This can lead to a sense of surrender and introspection.

Virtual reality-induced awe also appears to share functional characteristics with psychedelic mechanisms, and could act as a medium for a self-transcendental experience.

Psychedelic compounds have been used historically and in the present to successfully evoke mystical-type experiences. Combining VR and psychedelics may have an augmented, cumulative effect in producing a more “complete mystical experience” or “complete ego dissolution”, which may play an important role in the healing process.

Altered States of Consciousness Priming

MEs are preceded and facilitated by unique changes in consciousness that are often referred to as altered states of consciousness (ASCs). ASCs can be purposefully induced by a consumption of a psychedelic compound.

Evidence suggests that the ability to achieve an altered state of consciousness can be improved through practice, and that this ability is translational across different techniques. This is exploited in the training of American Navy SEALs, who practice common ASC methods to optimize their ability to enter a state of flow during missions.

VR has been recognized as a tool capable of eliciting ASCs, and can be used to induce visual alterations that closely resemble those brought on by classical psychedelics. This may have beneficial effects on clients’ expectation of hallucination effects and on pre-trip anxiety.

Therapeutic Alliance

A positive therapeutic alliance between the client and the therapist is essential for successful psychedelic treatment, and an inadequate therapeutic alliance may increase the likelihood of adverse psychological reactions during the dosing session.

VR therapies are reported to have one of the highest therapeutic alliance rates and satisfaction rates across various therapeutic approaches, and can be especially effective in facilitating a sense of safety and trust among the most traumatized or apprehensive patients.

Self-Efficacy

Preparation sessions in PP promote a non-avoidant attitude towards challenging components of the psychedelic experience. This attitude determines the depth of the psychedelic experience and its therapeutic impact.

VR has been shown to help patients overcome the fear of sharing their deepest, most disturbing thoughts with their therapist, and to increase self-efficacy in confronting difficult thoughts.

Expansion

VR can be used to prepare participants for the psychedelic experience by preparing them for unusual psychoemotional or bodily sensations that may occur. This can be done by challenging participants to control their impulsivity and sustain attention in gaming environments. VR can be used to prime patients for psychedelic experiences by inducing meditative-like or psychedelic-like states during the preparation phase.

Psychedelic experiences can be profoundly meaningful and have the potential to lead to pivotal changes in one’s feelings, attitudes, behaviors and even personality traits. Music can be used to evoke meaningful therapeutic experiences during dosing.

VR is successful at creating immersive mystical, spiritual or awe-evoking scenarios, which could be harnessed to construct an optimal setting that increases the chances of inducing a mystical-type experience. However, any setting provided for the participant during the dosing session may detract from the innately derived healing pathway.

ASC experiences are difficult to assimilate into daily life because they are often at odds with familiar sensations. The ineffable nature of the psychedelic experience may explain why current integration procedures find themselves limited. VR presents as a uniquely suited medium to reliably initiate ASC experiences during the integration process, and may also be able to facilitate greater recall of psychedelic experiences. However, its capacity to increase recall puts the participant in danger of having false or negative memories reinforced.

Transition

Most psychedelic drugs have a slow onset, a peak phase, and a post-peak phase. A latency period follows consumption of a psychedelic substance, and participants may experience stressful or anxiety provoking effects that prompt them to disengage from deeper immersion into the psychedelic state. VR can be used to gently nudge the attention back to the intention, for example by offering a personalized, patient-designed totem. This totem can combine visual and auditory elements that are personally significant. VR may be used during the pre-peak phase of an ASC to reinforce the intention and encourage a deeper immersion into the psychedelic experience among participants who have previously displayed difficulty in this regard.

During the resolution period, patients may begin to vocalize their antecedent psychedelic experience, which is often disordered but revelatory for patients.

Psychedelic experiences may present a challenge for therapists, but VR allows patients to explore their thoughts, insights and emotions without having to rely on language. VR could serve as a physical representation of a memory library, where information is recorded visually or verbally or both. This memory library can then be utilized during the integration process to further explore and discuss the elements that were already established, while adding new insights or actionables. VR may prove overly stimulating and impair the process of self-discovery, so scenarios should be flexible and responsive to allow for a participant-driven process of assembling the VR model from within the VR space.

Cohesion

VR can be used to promote a clear and receptive mindset during therapeutic sessions that revolve around the novel and impactful nature of the psychedelic experience.

VR environments promote detachment from familiar temporal and spatial reference points, and ground the attention in the here and now. Additionally, contextually rich models can be reapplied in precisely the same manner each time. Scenarios that promote relaxation, mindful presence and buffering often use serene man-made spaces, nature immersion, or outer space models. These scenarios are predominantly non-directive, characterized by low to medium intensity stimuli, with wide focal points that require minimal focus. VR scenarios used for self-practice should maintain continuity with VR models used during dosing, and should build on the goals of therapy. VR therapies have one of the highest compliance rates, and can significantly improve adherence to other treatments when used as an adjunct to therapy.

Rescue

Challenging experiences seem to play an important role in the psychedelic experience. However, resisting the difficult experience may obstruct the therapy’s beneficial effects, impact the resolution of the issue and catalyze the progression from a challenging experience to an adverse effect.

VR is significantly more reliable at overriding stress responses than current alternative methods, including two-dimensional visual displays of similar scenarios. It can be used as an immediate anxiety relief tool, or as a sobering tool during an over-challenging psychedelic experience.

To act as a rescue tool, VR needs to compete with the strongly engaging inner experience. It should have a rich contextual design, immersive sensory stimuli, dynamic, attention-demanding content and an interactive component.

Over-Stimulation

Virtual reality allows for a wide range of design alternatives, but the potential risk of over-stimulation has been raised by VR providers. Care should be taken when combining VR with psychedelic substances to avoid sudden changes in visual patterns, extremes of saturation or brilliance and spatial disorientation.

Accidental Exposure

A traumatic response can be triggered unexpectedly by any relevant cue, particularly in a vulnerable state induced by psychedelic substances. VR environments should be examined for presence of any cues that have personal resonance or could be associated with traumatic experiences.

Leading

VR environments can have a strong impact on the psychedelic journey, so it is important to balance providing mild stimuli to block distraction from mundane external realities and maintaining focus on the intention.

Distraction

In many PP protocols, external stimulation is kept to a minimum, and the participant is encouraged to focus their attention inward. Using VR during dosing should be carefully weighed against potential disadvantages, including overly leading the process of recall and sense making. Interactive VR content may compete with the effects of the drug and should only be used as a rescue function. Cognitive interaction and physical interaction should be avoided during dosing.

Cyber-Sickness and Physical Discomfort

VR stimulus can cause simulator sickness symptoms, most commonly fatigue, headache and nausea. These symptoms can be mitigated by careful consideration of VR design specifications, such as avoiding controller-based movements, minimizing gaming content, or maintaining an appropriate exposure time. The head mounted visual display, technical glitches or poor visual quality of the VR model may cause some discomfort, so participants with severe visual impairment may need to be excluded from treatment.

Resource Limitation

VR technology requires the development of novel protocols and procedures, as well as training of practitioners. The therapist must become comfortable with the VR software and hardware before it can be used.

Commercial Interests

Virtual reality is currently used as entertainment technology, but its use in therapy is largely unregulated. Scientific validation is needed before VR products can be used in psychedelic therapy.

SUMMARY

Psychedelic-assisted psychotherapy presents itself as a promising and attractive alternative to established psychiatric treatments. Virtual reality (VR) can be used to provide the most favorable environmental stimulus with a high level of control.

VR can be used to support treatments that use psychedelics by enhancing relaxation, removing familiar cues, encouraging mindful presence, deepening acute psychological and emotional states, and maintaining a hierarchy-free therapeutic alliance.

To maximize benefits from profound ASC experiences, including ME, VR can be used to prime occurrences of those states during preparation, augment their depth and facilitate their profound emotional impact during dosing, and enhance therapeutic utility by aiding revisiting of these states during integration.

When using VR in psychedelic psychotherapy, special care needs to be taken to avoid introducing potentially disturbing or traumatic triggers, distracting from the inner experience, or providing overstimulating or cyber-sickness inducing content.

CONCLUSION

We described features of VR that make it a promising candidate as a complementary moderator of therapies that utilize psychedelic substances. We suggest that VR could be used to promote a continuous, multi-sensory experience through the entire psychedelic journey.

AUTHOR CONTRIBUTIONS

AS collected, analyzed, and synthesized the evidence, PP created the main conceptual themes, and LD refined the manuscript and the language. All authors contributed and approved the final version of the manuscript.