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Are We (Virtually) There Yet?

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In June 2018, the FDA announced the approval of a neurorehabilitation device for patients recovering from stroke—an interesting instrument that looks somewhat like the Nintendo 3D games that those of you with teenaged children might recall with varying degrees of horror (the games, not the children, I hope).  Mindmotion Go and Mindmotion Pro (which earlier received FDA approval as a new medical device in 2017) are “gamified neurorehabilitation systems” that can be used on an inpatient or outpatient basis for post-stroke rehabilitation.  By attaching sensors to various body parts, patients engage in exercises that aim to improve gross or fine motor responses on tasks as sophisticated as simulated driving.  Psychologists who have worked with electromyographic (EMG) biofeedback equipment in rehabilitation settings are familiar with the principles involved, although the technology is considerably advanced over the biofeedback machines typically seen in such practices.

Other technologies are in varying stages of development.  There are “e-skins”—close-fitting wearable devices that contain multiple sensors that allow the wearer to manipulate objects in a virtual environment—and sensor-bearing artificial exoskeletons that already have demonstrated utility in assisting mobility in patients with spinal cord injuries.  These devices are predictably extremely expensive, but further technological development coupled with a reduction in price will undoubtedly make them more widely available to those with impaired mobility.

It is important to remember that such innovations are assistive, not therapeutic—they do not alter underlying pathology, although they can materially improve adaptive functioning.  Another very important consideration, and one that has already garnered the attention of the insurance industry, is the ease with which use of wearable technologies can be tracked by third parties.  Insurors are already speculating that wearable technology will allow them to collect data on an insured’s lifestyle habits, adherence to exercise regimens, and the like.  Another form of “wearable” technology, if you like, is the recent introduction of Abilify MyCite, the antipsychotic pill with an ingestible sensor that informs the patient (and others) when a pill has been taken by uploading data from the pill to an external database, where such information can presumably be accessed by healthcare providers and others.  Because far less expensive (or invasive) technology exists to monitor pill-taking behavior, it is not a great leap to presume that the primary impetus for this technology is to provide a remote monitoring system accessible not only by healthcare providers, but perhaps by the criminal justice system in cases where court-ordered medication has been mandated.

While the evidence base for rehabilitation systems that incorporate virtual reality video gaming technology is developmental, a 2017 Cochrane review suggested that interactive gaming devices had some utility, at least when paired with traditional therapies.  In general, the limited outcome data in this area appear to mirror outcomes found for EMG biofeedback enhanced rehabilitation—there is some evidence that such interventions improve outcome over traditional therapies, but definitive outcomes are lacking.  This is understandable, given the difficulty involved in assessing outcomes in what are unavoidably single-subject designs involving physically impaired patients who have suffered a significant cerebrovascular event.

Expensive (often prohibitively so), adaptive (not therapeutic), aspirational (not proven).  These are the same observations that were applied to new technologies in mental health a decade ago.  Indeed, a tally of PubMed citations using the search terms “virtual reality psychotherapy” suggests that research interest in this area began in earnest around 10 years ago, and peaked several years ago, with a modest decline since that time.  There were 20 citations in 2008, an extrapolation for 2018 suggest approximately 35 publications for the entire year, compared with a high of 132 in 2016.  While some might argue that this is typical for research in a nascent field, another explanation is that a number of investigators have not found anything terribly compelling in virtual reality psychotherapy delivery, at least as far as current technology allows us to use it.

Let’s look at the pluses and minuses of virtual reality technology.  On the one hand, a virtual environment may provide access for those unable to attend in-person sessions.  This might include those with physical limitations, remote locales, or those with severe mental distress, such as agoraphobia.  Patients who are fearful of stigma, or who wish to avoid any disclosure that they are in therapy, might also appreciate this approach as technically it is not a person but an online avatar that interacts with the psychologist’s online avatar.  At one point this author was involved in a project in which I established an “office” in Second Life with the intent of “seeing” military members with concerns about PTSD or other disorders.  Although the project never came to fruition (no patient avatar ever sat in my virtual office with the nice virtual Oriental carpet on the floor), it is interesting that the military was seriously investigating this as an option to increase access and reduce stigma among military members, who often remain reluctant to seek psychotherapy services out of fear (not entirely unfounded) that this will damage a career or negatively affect a security clearance.

On the other hand, practical issues surrounding virtual reality therapy are daunting.  Authentication procedures for determining the identity of the patient (and one or more avatars belonging to that patient) will be required.  Legally, jurisdictional issues will be prominent, and it is probable to the point of certainty that at some not-too-distant time a patient avatar will lodge a malpractice action against a therapist’s avatar.  It is important to note that platforms such as Second Life are not HIPAA compliant and were never designed to be used for provider–patient interactions.  Although the developer of Second Life (Linden Labs) is aware that their platform is being used for such purposes, they do not specifically track this type of usage and they have no plans to develop specific platforms for patient–provider interaction.

Virtual reality procedures have been tested with good preliminary effect in exposure-based interventions, where it can be presumed that a patient would be more willing to expose an avatar to a threatening situation than in vivo.  A recent British study evaluated use of a VR avatar to assist patients with acrophobia using a technique called immersive Virtual Reality.  This was a single-blind trial that compared treatments delivered via a therapist avatar to patients who wore against a no-treatment control group.  Patients wore VR headsets with attached sensors so that they could stand and move about during treatment, which was delivered in approximately six 30 minute sessions over two weeks.  At follow-up, patients in the VR treatment condition showed significant reductions in scaled scores of acrophobia.  While the authors noted that this was an expensive intervention, both from a technological and personnel standpoint (a psychologist remained in the treatment room with each patient), patient acceptance of a personalized avatar was high.

Other fascinating experiments have investigated whether patients suffering from auditory or visual hallucinations might be better able to engage in therapeutic dialogues with a computerized version of their hallucinations in order to gain greater control over them.  The answer here seems to be yes, this may be an effective way for patients to confront deprecatory or command hallucinations.  Unsurprisingly, it has also been found that socially mediated fears can be both induced and extinguished using virtual reality paradigms.

Telepsychology is different from gamified rehabilitation or virtual interaction with electronic representations of oneself (or one’s hallucinations), but our longstanding flirtation with telepsychology allows us to make some interesting comparisons.  It is easy to forget that the first instance of telepsychology happened more than 65 years ago when Nebraska psychologists conducted inter-city group psychotherapy over closed circuit television.  Since then, interest in telepsychology has waxed and waned.  In the 1990s, I was involved in the development of protocols for provision of telemental health within the Department of Defense.  Some of the issues we dealt with 20 years ago have been laid to rest.  Bandwidth, for example, was a major concern (few locales, especially smaller ones, had the electronic infrastructure to receive the very large data packets that streaming video then required).  Videography and video display presented other problems (few sites had the expensive videoconferencing equipment needed at the time, and getting displays of sufficiently high resolution to observe things like nuanced facial expression or fine motor movements was problematic).  These issues have now been solved, and telepsychology can now be conducted with a smartphone should one so desire.

Other issues are still alive.  Patient safety and patient privacy should continue to be major concerns for everyone practicing telepsychology, as should security of electronic networks and authentication of both patient and provider.  We confronted issues regarding patient safety (we decided that it was necessary that the patient receive care inside a healthcare facility where backup support would be available) and patient privacy (how could we be sure that the patient was alone in the therapy room on the receiving end)?

According to a 2017 survey, the vast majority of healthcare organizations intended to rapidly expand telemedicine services, even though reimbursement remained a major hurdle (approximately 50% of the respondents were reimbursed by self-pay).  A surprisingly large number indicated an intention to expand internationally.  A bill has been introduced in the U.S. House of Representatives that would allow telemedicine providers to prescribe controlled substances under certain circumstances.  The VA has recently changed policy to allow both patients and providers to conduct telemental health from outside VA facilities.

Numerous psychologists will decry the brave new world of electronic provision of psychological services.  Such conversations have a long, if relatively fruitless, history in the profession.  Every generation has its doomsayers who see technological innovations as an existential threat.  In the 19th century, our academic colleagues fretted that compressing written messages in order to minimize the expense of sending a telegram (i.e., telegraphic grammar) would fundamentally debase written language.  In the 1990s, the advent of the internet was seen as a harbinger of a degraded professional knowledge base.  What if students got their information from the internet, rather than from a textbook?  What would happen if a patient could instantly look up features of their diagnosis online?  Today, the smartphone is seen by some as a societal menace.  Are we creating a generation of asocial, if not downright antisocial zombies, incapable of meaningful interpersonal interaction?  But it is important to remember that while technology may shape the way in which our services are delivered, it doesn’t shape our professional standards and ethics.  Instead, we bend technology to adapt to such standards.  This does not mean that such technology won’t affect our practices in fundamental ways, and we must be increasingly vigilant against further encroachments on our and our patients’ privacy.

I imagine that many of you have recognized, as I did, that widespread dissemination of psychological information via the internet created a different doctor–patient dynamic.  In the past, patients relied on us as essential providers of information.  Now, patients are increasingly self-reliant in accessing information and what they seek is an educated perspective that allows them to synthesize the data they’ve collected.  In other words, patients rely less on us as providers of knowledge than as providers of wisdom.  And that is not a bad place for us to be.

Copyright © 2018 National Register of Health Service Psychologists. All Rights Reserved.

Further Reading

McMahon, E. (2017). Virtual reality exposure therapy: Bringing ‘in vivo’ into the office. Journal of Health Service Psychology, 43, 46–49.

Magnavita, J. J. (2017). Optimizing treatment with easy to use technologies: Updating your clinical toolbox. Journal of Health Service Psychology, 43, 42–44.

Ahmed, A. O., Hansen, M. C., & Lindenmayer, J. P. (2018). Cognitive remediation services for people with schizophrenia: Considerations for health service practitioners. Journal of Health Service Psychology, 44, 80–89.

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