Psychedelic-assisted psychotherapy is entering the virtual realm. Enosis Therapeutics, an Australian medical technology and research company, is exploring the integration of virtual reality (VR) into existing psychedelic protocols.
The company has spent 2 years developing an end-to-end program that incorporates VR into each phase of a psychedelic therapy treatment process. Psych Congress Network recently caught up with Enosis Co-Founder Agnieszka Sekula by email to discuss the potential benefits the company sees in augmenting psychedelic-assisted therapy with VR, the equipment and infrastructure it requires, and mental health conditions for which VR may be a good fit (and those for which it is not).
Editor’s note: This interview has been edited for length and clarity.
Psych Congress Network: How does Enosis integrate the use of virtual reality (VR) into psychedelic-assisted psychotherapy? Does this require proprietary VR equipment, or can a commercially available VR headset be used?
Agnieszka Sekula: We focus on the unique characteristics of VR as a state altering method that is synergistic and congruent with the psychedelic experience. VR is not just a container that creates a well-suited setting for the psychedelic experience; it is a buffer zone that provides the patient with their own, intimate world that expands the psychedelic experience beyond the duration of drug effects.
We use VR to prepare clients, not just for the dosing session, but for every session of the entire psychedelic-assisted psychotherapy process, easing the transition from daily life into an altered state of consciousness (ASC) therapy and promoting a sense of continuity throughout treatment. Although studies on this subject are still limited, daily practice shows that entering an ASC with 1 method increases the capacity to achieve an ASC with other methods. Navy SEALS use a wide range of state altering practices in their training, knowing that this will allow them to enter a state of flow much easier during the mission. VR primes the mind’s ability to enter an ASC, encouraging a deeper exploration of that state and when used during preparation and integration, a stronger sense of permanence in therapeutic engagement can be cultivated.
Another important example of how we use VR to maximize the potential of psychedelic therapy, is via a method of delivery that is currently pending patent rights. We call it Anchoring VR.
Our anchoring model is used either at the very end of the dosing session, at that critical time of return from an ASC back to normal or wakeful consciousness in the psychedelic-psychotherapy model, or at any point of the dosing phase in the psycholytic model.
Our VR scenario allows us to record those invaluable, raw insights while the client is still immersed in their intimate, alternate world, enhancing the process of first narrative formation.
Unlike conventional, analog methods of therapeutic engagement, VR offers multisensory methods of self-expression that can be recorded and build into a personal memory library. That library is then revisited on days and weeks after the dosing session, anchoring both the emotional aspects of the experience, as well as the more explicit yet chaotic accounts of the first narrative. This allows for the process of meaning making to be centred on that raw, personal, qualitative data, and extends the access to the experiential memory of the altered state of consciousness beyond the psychedelic session.
Most importantly, this meaning-making process takes advantage of the most unique features of the psychedelic experience, without overreliance on cognitive methods that current talk therapy is based on. Integration becomes more rooted in emotional, embodied, experiential aspects of therapy, postponing the more analytical, cognitive processes until much later in the therapeutic engagement.
Last, we have developed this as a software that is compatible with most commercially available VR headsets. The complete protocol uses a platform that incorporates all our VR models and requires both a high-end gaming computer as well as cabled VR headset to work at its most optimal level. But we also provide standalone VR models for individual clients, some of which can be used on more basic VR headsets or even with 360 goggles in some cases.
What benefits does the use of VR add that patients in psychedelic-assisted psychotherapy might not otherwise experience?
Sekula: VR is greatly misunderstood and known predominantly for its highly stimulating use-cases in gaming and entertainment. Conversely, VR’s major contribution to the psychedelic-psychotherapy model may come from its ability to subtract stimuli that otherwise keeps clients tethered to their daily, familiar reality. VR eliminates all external distractions, while gently nudging attention inward through carefully designed elements within an unfamiliar, abstract world. This enables a sense of openness, letting go and staying curious about the novel experience, which is precisely the approach advocated for approaching the psychedelic experience.
VR is also an independent world that is unfamiliar in equal measures to both the therapist and to the client. This VR world can be co-created by the client from within the experience, which grants them a sense of ownership of the space. This is not possible within the real-world environment, where the client is nearly always a visitor in the space that belongs to and is under the control of the therapist. This shared ownership of the setting changes the dynamic between the 2 parties, levelling the hierarchical gradient that would otherwise exist between the person being treated and the person offering treatment. Instead, the alternate world can be explored by all, fostering a sense of embarking on a journey together.
Last, VR can play a role as an integration tool both during therapist led integration sessions as well as after the culmination of these sessions, to function as a self-practice tool. Clients retain access to models they have created for themselves, with their entire therapeutic trajectory being stored within those models. VR has the capacity to act as an all-encompassing, interactive anchor of the psychedelic experience, which is instrumental in building a habit of self-practice, allowing integration and re-examination of psychedelic lessons to continue beyond the patient-therapist sessions and into a model of life-long healing.
Are there specific conditions being treated with psychedelic-assisted psychotherapy for whom it would be especially beneficial to integrate VR? Are there mental health conditions for which VR might not be a good fit?
Sekula: The main target of our approach is maximizing the therapeutic effects of an altered state of consciousness; hence, our VR-PP protocol and our VR scenarios are both substance and indication agnostic. If you consider the main functions of VR that we are promoting—buffering of external stimuli, inducing a mindful state, priming the capacity to enter an ASC, augmenting peak states—it is clear that VR is able to complement treatment that uses any psychedelic substance regardless of what the treatment condition may be. The goal is to both ease and to maximize the challenging but highly potent moments of transition, be it from daily life into a therapy session, into or out of an ASC, or even from guided therapy into the process of self-practice. The benefits we gain through this approach—sense of permanence through treatment, increased ownership of the healing process, augmentation of experiential aspects of psychedelic treatment—are in fact beneficial not only regardless of indication, but also regardless of therapeutic framework used.
Broadly speaking, use of VR is suitable for any indication that psychedelic-based treatment is suitable for. Particularly in cases when clients struggle with letting go, struggle to stay open to the experience, have high levels of anxiety before the experience, make clear attempts at resisting surrender to the psychedelic state, or require further therapeutic support above and beyond formal integration sessions or after the end of therapy, VR can be of huge benefit.
A specific example may be a client who lacks a reliable support network and has no access to additional services after the conclusion of a limited, formal integration process. Access to their VR models, which they constructed from within by themselves and that serve as a memory library of their psychedelic experience, may offer additional support and enhanced sense of continuity of treatment, which are so important in maintaining treatment outcomes.
There are, of course, conditions that psychedelic therapy itself is not currently indicated for, such as dissociative disorders or psychotic-spectrum disorders, and inclusion of VR does not broaden that spectrum of potential indications. Additional exclusion criteria that are VR specific include history of motion sickness, demonstrated history of cyber sickness with VR exposure, seizure disorders, and very poor eyesight.
Can you share any data or research demonstrating the impact that adding VR to psychedelic-assisted psychotherapy has had?
Sekula: There is unfortunately no published research to show now. Our paper was, after all, the first academic publication tabling this synergistic relationship. We are currently awaiting ethics approval to run our first case studies, which should most likely be taking place any day now. The data that we are looking at with quantitative and qualitative methods are based largely on the innovative application of AnchoringVR and its ability to re-evoke the emotional, embodied, altered state experiences on days after the dosing session. If successful, this means that we can rely on VR to enhance access to the psychedelic experience on integration sessions that do not require repeat dosing. We hope this to be the first step in refocusing on the emotional, experiential aspects (rather than the cognitive) of the psychedelic experience during the integration process, given that these are the features of psychedelic-assisted psychotherapy that are the most unique and worth building on.
During our case studies we will also look at the level of acceptability, feasibility, and appropriateness of combining VR with psychedelics, and at any subjective benefits that were brought on by VR.
Once we have the results analysed and published, we will be looking at running a larger clinical trial at the end of the year together with Swinburne University.
As an organization, what’s next for Enosis with regard to VR?
Sekula: We are continuing to develop and add features to our VR models. This process is informed by the feedback we receive from our advisory board, which is mostly comprised of highly experienced clinicians and psychedelic scientists. We have selected our advisory board members very carefully to cover the full spectrum of insights that we require to ongoingly improve our products—from experienced psychedelic therapists Rosalind Watts, PhD, and Renee Harvey to psychedelic researcher Paul Liknatzky and VR professor Murat Yucel, just to name a few.
We are also about to embark on the first ever scientific examination of the use of VR in combination with psychedelics. This is to take place in the Netherlands, in collaboration with Swinburne University, represented by Professor Luke Downey, and Belgium Psychedelic Society, represented by Lennart Cok. Those case studies will clearly validate a path that has been of great interest to some and a cause of great apprehension to others.
Is there anything else about your VR-related initiatives that you’d like to add that we have not touched on yet?
We would like to reinforce the academic first approach that we are taking toward development and implementation of VR in psychedelic therapy. As a company that is led by 2 scientists, we want to at the same time inspire ground-breaking innovation and focus on collecting robust, comprehensive evidence. We see enormous risks in attempts to integrate VR into psychedelic therapy not being rooted in evidence and clinical feedback, and as result take a slow, measured, and data-driven approach to everything that we do. It is why we are building toward a full clinical trial in the fourth quarter of 2022, which will be a landmark for this field but will also reinforce the science behind the methodology we have taken, rather than a product being developed from an entertainment and gaming background and being shoe-horned into a therapeutic framework.
In addition, we see the potential of VR being far beyond simply the provision of beautifully designed settings and environments. While that is undoubtedly a use case of VR, it ignores the myriad of possibilities to target very distinct neuropsychological mechanisms that dovetail with the psychedelic experience, and the process of memory formation and reinforcement that underpin the direction we are taking. This requires a lot more than just aesthetically pleasing VR design but instead a deep understanding of the underlying science and the therapeutic principles behind psychedelic therapy.