Psychedelic-assisted psychotherapy (PAP) is under investigation for its potential in treating psychiatric conditions. A recent paper, published by academics Agnieszka Sekula and Dr. Prash Puspanathan, outlined how virtual reality (VR) might be incorporated into aspects of the PAP process. Sekula and Puspanathan are aiming to create a protocol for VR and PAP through their company, Enosis Therapeutics. Technology Networks spoke with the duo to discover the potential of VR in PAP, what visuals users might encounter and the challenge of leading the nascent field with data-driven approaches.
Ruairi J Mackenzie (RM): What roles do you see for VR in PAP?
Agnieszka Sekula (AS): We think that VR can be utilized in a variety of different ways, thanks to its ability to enable a state of relaxation, buffer from external stimuli. evoke awe and prime altered states of consciousness – all things that we go into detail on in our paper. With regards to the way we see this being used within the psychedelic protocol, the first is the transition. This is using VR to ease participants into and out of an altered state of consciousness. So, it's used to either train someone in entering an altered state to make it easier on the day of the dosing session, to ease the anxiety around the dosing session or to engage someone in the sense of surrender and letting go after the dosing has already started, during the pre-peak phase.
On the other side of that there is the return to normal consciousness, which is our current point of focus. This is when the memory of the experience is still very vivid and very strong, but the person is already engaging in some sort of exchange with the therapist or interaction with their immediate surroundings.
This is the return that we are trying to capture because a lot of meaning-making of the psychedelic experience happens during that time. For our models, we use that time to record those memories and insights from the experience so that they can be better used during subsequent integration.
RM: The idea of using VR during the peak of a psychedelic trip sounds intimidating. Do you see VR as something to use adjacent to the trip rather than during it?
Prash Puspanathan (PP): I think it's important to clarify some of the misconceptions. I think a lot of people have an immediately adverse reaction to the idea of bringing any sort of tech like VR into the psychedelic experience, because the misconception is that we're trying to get people to wear a VR headset the whole time they're going through the psychedelic experience. That is definitely not the intention.
In fact, we detail that in the paper as something that would likely be counterproductive, primarily because you'll be leading the entire psychedelic experience, and that is certainly not the intention. The primary purpose of the utilization of VR is to optimize and to act as a modulator of the entire PAP process. We need to consider it as a process that starts with preparation, and then you have dosing and then you have the integration sessions after. The role of VR is across that entire process, not just dosing.
As for the dosing session itself, as we've described, VR would be used mostly in the pre-dosing stage, and in that liminal phase as you're emerging from the psychedelic experience. This would scaffold the individual's experience and allow it to have more sustainable and enduring effects. But it certainly isn't to be used during the peak phase.
It's quite a topical issue at the moment in the psychedelic sphere. There's been some criticism leveled at some of the more recent trials that have come out. Due to of resource allocation issues, there are only a limited number of integration sessions offered to participants. And because it's all happening within the trial environment, the moment that trial process ends, participants are often left without a scaffold. The trial ends and they don't have anyone to continue following them up. The researchers who follow them up during the trial don't have the resources to continue to follow the model outside of the trial.
The timing is serendipitous in a way because the usage of VR as an integration tool, by building it up into something that the participant is very comfortable with, allows for self-practice and self-integration, even after, in this case, the research trial. If you fast forward three or four years down the track when this is available for therapy, it could mean that the cost of the overall process comes down significantly, because therapists' time is often the most expensive part of the therapy process.
RM: What kinds of images would be shown to someone in the pre- or post-peak phase of the psychedelic experience?
AS: You’re basically asking us for our secret sauce. I can speak about the one that we are using most prominently at the moment on the return to normal consciousness immediately after the trip. After feedback from users and our advisory board on this model, we realized that when it comes to VR with psychedelics, less is more. We have to very carefully dose the kind of stimuli that we want to be using and introduce them slowly after the trip.
Our scenario is very simple and serene. We are using only the elements that there is specific utility for. In our case, we are using little anchors, in the form of stars, that people speak to about the insights that they had during their experience, or emotions that came up. They are asked to express them vocally, and they speak to those little stars that they pick up.
They are surrounded by this library of stars, and they pick whatever star resonates with them and record that insight or emotion. They basically build their own constellation of stars, which serves as a form of memory palace. Then, during the integration process, they revisit that memory palace, and they can take the stars that they've recorded in, and that is played back to them in their own words, so they can be reminded of what their insights were.
What we find is that it's quite difficult to remember, after the trip, what you've been through, and even if you remember something, it's usually quite vague, or only the very key insights are remembered, a lot of the other things are lost. Having the ability to go and be reminded in your own intimate little world means that people go back to that sensation that they had during the experience much more easily. Almost an altered type of state of consciousness can be evoked in that way.
RM: How would you envisage a trial involving the combination of VR and PAP being set up?
AS: We are preparing case studies together with a therapist in the Netherlands. We are following his protocol, which is based on a retreat model that lasts two to three days, with one preparation session, one dosing session and one integration session. We are introducing our VR model at the point of the first narrative process during a dosing session, and then again during the integration process, to test whether those memories are evoked, and whether people do remember more when they're immersed in those environments.
PP: Towards the end of this year, we're planning towards a full-scale clinical trial. And in that case, it would not involve a retreat model. We would use a model more familiar in traditional psychedelic therapy trials: with more preparation sessions, many more integration sessions and a longer longitudinal period. That obviously is a far more expensive process and so the case studies help us refine our models.
RM: What do you think are the key challenges of adopting the VR process in psychedelic therapy?
AS: Firstly, there are challenges we see overall of introducing VR into psychedelics. We have been working for the past two years to make sure that those challenges do not happen during our case studies. These are the side effects that we anticipate with scenarios that might be overstimulating, overly leading or distracting for the experience. There are, for example, accidental exposure elements that might trigger someone if the content isn't well thought out. And obviously there are things like cyber sickness or physical discomfort that need to be considered. I think we have managed to develop our scenarios in a way to make sure that none of those things happen.
PP: In a broader sense, the main reason we are very insistent on pointing out limitations is that we're starting to see a greater interest in psychedelic therapy and VR as a combination from a commercial angle, from gaming and entertainment companies. We very clearly want to point out that in introducing any form of tech into a scientific process, it is imperative that it is a data-driven and academically-driven process first, not coming from the other angle of being designed first and then shoehorned into the psychedelic therapy process without consideration of the limitations that we have outlined. That was really important for us to put out there.
We find ourselves, in a way, creating this field from the ground up, when you consider that ours was the first paper on this. We don't want that field to be completely ruined by commercial interests and by gaming and entertainment angles that may weasel into the psychedelic space that aren't clinician led, that aren't researcher led, that aren't academic led and aren't data led. That, for us, was pretty crucial in terms of outlining potential limitations.
AS: One of the most important things for us is that our solutions are very much patient driven. The concept behind providing someone with their own intimate world where they can self-express was to empower them to take more control over their own healing. The totality of the process of healing is predominantly composed of three main elements: the drug, the therapist and the context. The drug and the therapist are completely outside of the patient's control. But the context can be within their control, but it's not being utilized in that sense at the moment. By providing a space within VR where they can be in full control over that world, we want to empower patients to take control over their own healing pathway. We hope that we will inspire them to continue integration on their own and continue with self-practice for as long as they can.