Editor’s note: This article is part of PRF’s featured content series, “Investigating Virtual Reality for Pain Management: Past, Present, and Future,” which has been made possible thanks to a generous grant from the MAYDAY Fund.
Brennan Spiegel, MD, MSHS, is the Director of Health Services Research for Cedars-Sinai and Director of the Cedars-Sinai Master’s Degree Program in Health Delivery Science (Los Angeles, California, USA). He directs the Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), a multidisciplinary team that investigates how digital health technologies – including wearable biosensors, smartphone applications, virtual reality (VR) and social media – can strengthen the patient-doctor bond and improve outcomes at a lower cost.
Transcribed here, this interview with IASP’s Associate Director of Publications Greg Carbonetti provides details about Brennan’s work at the Virtual Medicine Program, the benefits and pitfalls of implementing medical extended reality (MXR), and the process of writing his book, VRx: How Virtual Therapeutics Will Revolutionize Medicine.
Would you mind telling us a little bit about yourself and what made you become interested in immersive therapeutics to help treat a variety of conditions?
I’ve been interested in digital health for quite a long time and my research, which initially was focused on gastroenterology and on public health more broadly, began to reorient towards digital health technologies.
I see digital health, broadly speaking, as a way to amplify our ability to deliver care to people outside of the traditional settings of a clinic or a hospital – in communities and areas where people live, work and play, where people spend 99% of their lives. Nowhere near a hospital or doctor, but out in the world. Digital health, Bluetooth technologies, wearable biosensors, and so on have become a set of tools that allow us to reach beyond the four walls of the hospital, to engage people meaningfully where they are, and give them tools to help manage biopsychosocial distress.
That’s where I had been focusing for quite some time when I first learned about virtual reality, which I really had very little knowledge about. I knew it as a gaming platform, for entertainment, but not necessarily as a treatment approach for medical practice. When I first used virtual reality and experienced the almost ethereal feeling of being transported into another realm, a fantastical world, it was clear to me that this was technology unlike any other, and has the ability to engage the human mind spatially, to feel as if you are in a different place or a different time.
I realized that this was a powerful tool that, if used appropriately, could be used to help improve the lives of patients and give them access to capabilities they didn’t necessarily know they had access to. So that led to my interest in virtual reality and doing a wide variety of research studies to explore that hypothesis.
In 2020, you published a book titled VRx: How Virtual Therapeutics Will Revolutionize Medicine. Can you tell us a bit about that process and what you learned along the way?
I had a lot of fun writing that book, and it was very exciting! It was a culmination of a lot of research and a lot of thinking about technology’s role in modern medicine, virtual reality in particular. Really, the book is about what the technology is teaching us about our own minds, our own psychology. What could it teach us about the intersection between clinical medicine, health technologies, psychology, neuroscience, and even theory of mind? The book really addresses all of those different areas and tries to weave together a narrative about where we are in modern medicine that we would even think of using something like VR to help manage conditions like chronic pain, schizophrenia, labor and delivery, depression, irritable bowel syndrome, or migraine headache, and over 50 other conditions.
Now, what does that say about our mind, as the common denominator for all of these conditions? And why is it that virtual reality, which is a form of simulation, ends up being such a powerful driver of improvement across all these varied conditions that don’t seem to have a whole lot in common? The book, in the end, was almost a philosophical exploration of these concepts driven through the stories that I’ve seen with the patients we’ve treated.
It started off as a much more modest project, but as I got further and further into it, I realized that there was really a rich narrative to weave together from all of these different threads across many different disciplines, and that’s what VRx is really about.
In the book, you mentioned a few surprises as you got into the immersive therapeutic space. Is there any one instance that sticks out to you the most?
Well, we started hearing some anecdotal experiences, which led me to want to study VR more and really understand: In whom does it work, when does it work, and how big is the effect? It doesn’t work in everyone all the time – it isn’t some panacea that’s going to cure people of their most difficult moments – but there are moments where that does happen.
Just recently, I had a patient in the hospital who had experienced very severe abdominal pain for many years as a result of a surgery. And it was so significant that this individual could not eat anymore and was getting all of their nutrition through total parenteral nutrition because the pain was just so severe.
When I really sat down and talked to this person for quite a while, it became clear to me that they have also experienced a tremendous amount of depression, anxiety, and mental health distress as a result of living like this for so long. We talked about how when we look on X-rays of the abdomen and we look at pictures of the abdomen, we don’t see any clear reason why food can’t go through there anymore. And so we wondered if there was something else inhibiting the food and how much of that might be just the anticipation anxiety, in their mind, that pain was going to occur. So we tried virtual reality, and it was so powerful and so effective that within five days the patient started eating – after not having eaten anything in months! The pain had significantly dropped within the course of just a few days in the hospital; they were walking around the hallways, talking to people, socializing, and amazed by what had occurred.
To be clear, it could come back; it doesn’t mean we’ve cured the patient. But seeing and hearing those kinds of stories is so profound; those are the moments when I realize that, as a doctor, there are very few experiences like that where I can so quickly and meaningfully change somebody’s life. Yeah, it happens. That’s why we go into medicine; we save lives sometimes. But doing something like that without using a medication, just engaging the mind so that the healing occurs from the inside-out rather than the outside-in, was probably one of the biggest moments for me in all of this work.
How do you think clinicians could extend the therapeutic effects of VR once the patient has exited or once outside of the clinic? Is that something you are looking into?
This is a very important question, because it’s not all that helpful if VR only works when you’re wearing the headset. Now, that is certainly useful when, for example, a child is undergoing venipuncture or a patient is receiving a lumbar puncture, spinal tap, or is undergoing some painful procedure and in the very short term needs some distraction to help with the pain experience. For chronic pain, it’s different.
In the case of chronic pain, what we need to do is not just distract. That’s not a winning strategy; it’s not durable. We need to change the brain itself. The brain is a shape-shifting organ, and like any other organ in the body, it can change. It can change for the better and also change for the worse. We know that when it comes to chronic pain, cognitive behavioral therapy (CBT) is highly effective. And that’s because we all know pain is experienced, ultimately, in the brain. Sure, there can be tissue damage, there can be peripheral disease that’s leading nerves to fire, but when we get to the brain, at some point the brain is so overwhelmed with chronic signals that it starts generating its own pain experience – this is so-called nociplastic pain – to the point where you can completely fix the underlying tissue damage, but there might still be a lot of pain, and this perplexes doctors.
So yes, the mind is medicine, and what that means for virtual reality is that VR is a powerful way of affecting the mind. Just like any muscle, if we do this consistently, what we’re doing now is we’re training the mind – over the course of typically eight weeks – to learn how to experience pain differently. And this is nothing new. CBT has been around a long time, and spiritual practices have been around a lot longer. We all know the mind is medicine, and we know that the brain and the body are interconnected; they’re not two different things.
VR is simply a tool to standardize the mental conditioning of the mind so that it learns, over time, how to think differently so that when you take that headset off, you don’t need the headset anymore. We don’t want people living in virtual reality; we want people living in real reality. And we want them to have learned something profound about their mind and body in the VR that they then take with them. So really, VR is a learning platform to expedite or accelerate the changing of the mind, so to speak.
Do you think there are any drawbacks of VR? As this technology continues to progress, are there any issues that come top of mind that we really need to think about?
Definitely, that’s a topic that I address in the book as well. I have a chapter called “Primum Non Nocere” (at first do no harm), which is part of the Hippocratic oath that clinicians take. In any event, dependence is certainly a concern. Although I’m pleased that we haven’t seen that in our research, that’s not to say screens can’t be highly addictive – they are. Screens are changing civilization as we know it.
There are, at times, good and, in [other instances], not so good effects. VR is a screen, and it just so happens there is, thankfully, almost a built-in “anti-abuse” effect, as I call it. Antabuse (some may be familiar) is a medication that is used for people who become dependent on alcohol; it can cause them to feel rather sick if they drink alcohol. Somewhat similarly, if somebody is in virtual reality for a long enough time, they start to get dizzy and a little nauseous. And, as a result, if you want to play a first-person game, most people would rather play that game on a two-dimensional screen, for hours and hours, not in virtual reality. Instead, what we’re seeing, for the most part, is that VR games are exciting and interesting, but most gamers are going to be spending hours and hours on two-dimensional screens, not three-dimensional spatial screens for the reason of cybersickness.
When we create our VR programs, we’re really thinking about how to teach people something meaningful that they can then apply in their real lives, get out of the headset and move into the real world. Our goal is to not need the headset. Ideally, you won’t need it after the roughly eight weeks of treatment and you can just come back to it when you need to.
What are you conducting research on right now that’s really exciting you?
We have a number of ongoing studies right now that I’m very excited about, that involve spatial computing and now, increasingly, artificial intelligence. And really bringing the two together to augment each other, in this case for mental health support. We’ve done work recently using the Apple Vision Pro and other headsets, including the MetaQuest, to create a mental health support tool that uses a form of artificial intelligence and allows patients to engage with their own mental health within spatial environments. For example, you could imagine if you’re in a beautiful world and that world could change in meaningful, positive ways, depending upon what you’re talking about.
This could be anything. Imagine finding yourself in a Japanese rock garden, a meditative environment with beautiful music playing because the AI recognizes that you are anxious. This could also extend to something completely unexpected, like maybe you’re talking to AI about your gender identity, and the AI might deploy rainbow-colored butterflies that start to fly all around you in a beautiful forest. The software could use very subtle ways to try and generate a reality – my team calls that “GR” or generated reality – to augment not just the conversation but to use many of the senses – visual, audio and so on – to engage the mind in a way that is potentially even more meaningful than traditional talk therapy.
We’re experimenting with this now and have found that many of our patients find it really appealing to experience mental health support in AI-generated virtual reality worlds.
Similarly, we’re really focused on trying to create tailored experiences. When people talk about virtual reality for pain, let’s say, they don’t necessarily think about a specific program. They think of VR like it’s an intervention, but VR is like a syringe: It’s not the syringe that matters; it’s what medication [is] going through the syringe that matters.
VR is just a platform. What matters is what our patients are seeing, feeling, hearing, and experiencing. That’s the software. And it might use AI, in the case that I just described, or it might not, but the goal is to have a highly tailored experience. So we’re now developing focused VR programs for different types of pain.
As a gastroenterologist, I see a lot of visceral pain. Often, we think more about somatic pain, musculoskeletal pain, but don’t always think about visceral pain. Turns out, there’s a whole bunch of paradigms around how to alleviate visceral pain, and a lot of them focus on gut-directed cognitive behavioral therapy. Accordingly, we’ve developed another program specifically to deliver gut-directed CBT for abdominal pain. There is currently an NIH study examining this intervention to see if it can help people with irritable bowel syndrome, which is the most common visceral pain condition in the world.
So those are examples of the exciting projects where we’re focusing our efforts right now. Some use AI, some don’t. But all are trying to be more specific to take advantage of VR, and make it a really tailored, bespoke experience.
Where do you think this space will be in 10 years? Will there be VR in clinics throughout the country, in multiple healthcare contexts, both inside and outside of pain management?
I think the answer to that will depend on how quickly we can develop form factors that are useful to people. Right now, the existing headsets are quite wonderful in their ability to transport people, but they’re not yet something that people can wear in everyday life. The closest we have to that right now, that goes on a face and has a virtual element, might be the Meta Ray-Ban glasses, which really are just AI in a frame with a camera. But to get to the point where true VR or mixed reality experiences are possible on glasses, like the ones I’m wearing right now, is still a long way off. But once that has been accomplished, and it seems inevitable that it will be – I don’t think there’s any physics that disallow this to occur – then, we have a scalability opportunity to really involve VR or mixed reality in everyday decision making about health and everything else.
Let’s say, once you get to work, and you want to escape for just a moment, you tell your glasses to give you a 10-minute relaxation break and you don’t have to put on a whole headset that’s going to mess your hair up or sit heavy on your neck. Once we get there, yeah, I think we’re going to be seeing more clinics. As it is, we’re in a position where we need to see more clinics. I’ve been talking to a number of different people, also in other major healthcare systems, who are interested in developing clinical VR services.
But even right now, we don’t have to wait until sci-fi glasses come out. We can really be delivering high-quality medical extended-reality interventions through clinical programs right now! We do this at Cedars; it’s just not yet in its own official clinic. We also bring it to the hospital, and we use it when we’re asked to. But developing more clinics is something that I expect we will definitely have in 2035. I’m hoping that even within the next five years, we’re seeing a lot more of these clinics.
Gregory Carbonetti, PhD, is the IASP Associate Director of Publications and an avid New York Jets supporter.
More information:
Virtual Reality, Cedars-Sinai
Featured image:
Brennan Spiegel, MD, employs virtual reality to help a patient combat pain. Photo by Cedars-Sinai.