Pharmacy Times interviewed Agnieszka Sekula and Prash Puspanathan, MD, co-founders of Enosis Therapeutics, an Australia-based medical technology and research company investigating the introduction of virtual reality (VR) into the psychedelic therapy space.
Alana Hippensteele: Hi, I’m Alana Hippensteele with Pharmacy Times, and joining me Agnieszka Sekula and Prash Puspanathan, MD, who are co-founders of Enosis Therapeutics, which is an Australia-based medical technology and research company investigating the introduction of virtual reality, or VR, into the psychedelic therapy space. They recently published the first academic paper examining the synergistic applications of VR technology and psychedelic-assisted psychotherapy to explore how clinicians and researchers are thinking about therapeutic environments and overcoming barriers that may obstruct existing psychedelic protocols.
So to start, what led you both to investigate the intersection of VR and psychedelic therapy initially?
Agnieszka Sekula: So my background is in biomedical technology, and I've used VR for a range of different purposes in field of science and medicine, and it was clear to me very early on that VR has very powerful therapeutic properties.
I had then pursued another master's degree in psychology, and as I was doing that, I came across altered states of consciousness as a therapeutic modality. I was interested in how VR could help with those altered states and how we could induce altered states in order to be used for patients clinically.
Prash and I started collaborating on a different paper together on altered states, and the conclusion of that paper was that perhaps combining different modalities at the same time might have an augmented effect and enhance patient outcomes.
So looking at those conclusions from our paper, we thought that using virtual reality and a different state altering method, perhaps a pharmaceutical one, could lead to better outcomes. Given Prash’s experience is with psychedelics, and he has a vast knowledge on that topic, we started discussing the potential synergies between VR and psychedelics, and the conclusions that we came to was that we should probably use those 2 modalities together.
Alana Hippensteele: Right. What are some of the environmental factors at play for patients during psychedelic therapy?
Prash Puspanathan: Truly, when you're talking about psychedelic therapy, any factor in the environment plays a part—no factor almost is too small or too large. So everything from the people you're with, whether it's the therapist or not, how warm the room is, how the room feels—sort of cold and unwelcoming or whether it feels warm and inviting—the days before the time leading up to it, and how the patient comes into that room—all of those factors do play a part. So really thinking about designing the experience of a psychedelic therapy session requires a really in depth understanding of all the different factors that may make up that specific person's environment.
But the flip side of that is it also gives you a lot to possibly tweak and optimize. There's not much that we can do in an analog manner in terms of actually modulating the physical environment around you. But the great thing about working in VR technology is that there's so much more that you can tweak by digital means than you necessarily can in an analog space. That, for us, has been one of the most important realizations, and one of the most powerful techniques that we've been able to utilize.
Alana Hippensteele: Right. How might environmental design, such as the inclusion of greenery or the lack of it, impact the experience and impact the pharmaceutical effects of psychedelics in a clinical setting?
Prash Puspanathan: So the origins of psychedelic therapy, as much as we know it now in a very clinical setting, and it's being used in sort of therapeutic settings that are modeled after modern clinical methodology. Psychedelics, for the most part, have been used in sort of ritualistic shamanistic settings, which have generally been in nature. That's still what's often replicated by more recreational psychedelic users who try approximate as close as possible to that naturalistic type of setting.
The benefits again, they haven't been empirically stated necessarily. But certainly anecdotally, there's usually plenty of evidence that connection with nature, connection with Mother Earth seems to be a very common theme that flows through the psychedelic experience. As a result, it is a perfect adjunct to any sort of therapeutic or intellectual exploration by the use of psychedelics.
Again, using analog means, that's not always that easily achieved when you're working in a clinical model. Mainly because most of the settings happen in hospital environments or clinic environments, and the access to lush greenery isn't necessarily always there in a therapy room. Again, while it may not be as perfect as being in the middle of the Amazon, using virtual reality to approximate that sort of lush environment, understanding that the environments that can be created by virtual reality can be incredibly immersive, incredibly realistic. While in that sense of open immersion in the VR scenario can come as close as we possibly can within the analog limitations that we have towards recreating that experience.
Alana Hippensteele: So how could the use of VR affect the patient's experience of setting during psychedelic therapy?
Agnieszka Sekula: So the beauty of VR is that it allows a whole range of possibilities, and that's the type of stimuli and intensity of the stimuli that we can provide, but also the type of stimuli and the intensity of stimuli that we can subtract.
So when most people think about VR, they think about a gaming environment, they think about something that is very immersive, but also quite intense, as a setting, as a scenario. But VR is very powerful at buffering all the external stimuli, which is incredibly important in this case, given that the psychedelic experience is impacted by anything within your environment. Having even a therapist there sitting and looking at you, or having a painting, or an arm chair, or a door, or a clinical room reminds you of being in this clinical environment that is not your own, that is not your personal space, you're a visitor in that space. VR allows you that space that is your own. Taking away everything that is around you, that doesn't serve you and gives you the setting that you can build by yourself.
So, one of the ways in which we use VR is by allowing patients to create and build their setting from the inside out in the process of preparation for the psychedelic session. So they've got the environment that they feel empowered within, that they can trust completely, that they're not just visiting like they're visiting a clinicians office, but it's their own and that they build, and they have full control over. So that's in the process of preparation, for example, and that's a sense of empowerment that we try to install in patients.
Another use of VR is transitioning from normal consciousness to altered consciousness and back from altered consciousness to normal consciousness. These are the most difficult parts of the psychedelic experience in terms of the sense of letting go and surrendering to the experience fully. Patients can struggle to surrender and to let go of any anxieties that they have around the experience right before that, before the full effects kick in. We can use VR to ease that transition, we can use VR to take away any distractions of the external world and put them in that space where they're fully immersed, fully focused on their intention and on what they're about to experience and try to direct them a little bit to that sense of introspection, to that mindful state that VR is very good at inducing.
Then, following the experience immediately after, VR can be used to anchor the psychedelic experiences to act as a as a place where patients can experience the first narrative, which is the process at the end of the dosing session where they start to communicate the experience or they start to come back and they try to make meaning of their of their experience, but the experience itself is still very vivid, so it's very hard to communicate.
This is very unique period of time where the experience is very vivid, but we want to be able to communicate with them—that communication is very difficult. So, face-to-face communication with another human being is very challenging, and it seems almost surreal. So VR can be used as this buffering zone as this transition zone, that is the in-between world to continue that very intimate engagement from the patient's perspective, and where they can give the first narrative account without having to face the real world.
Prash Puspanathan: I was going to say you asked about setting, and how VR can be used in setting, and I think we've talked a lot more beyond that. I think what that points to is that I think when a lot of people think about even the possibility of VR being utilized in psychedelics, they think very simply about its use to just create a beautiful setting in the background. Whereas the reality is that is just the tip of the iceberg of possibility. The true value, the true potential of the use of VR is far beyond just creating beautiful settings. But it's in some of these mechanisms that Agnieszka has described, which is very distinctly targeting particular mechanisms that are relevant during the psychedelic therapy process, and working out how to optimize it, how to reduce some of the current deficiencies that the analog system just has to tolerate.
Alana Hippensteele: Absolutely. Yeah, that's fascinating. So you mentioned aspects of the patient feeling a bit less comfortable in a space that is not their own. How might the use of VR impact some of these power dynamics that might be in place between a therapist and a patient during psychedelic therapy that may come from either setting or may come from social dynamics and other areas of that relationship.
Agnieszka Sekula: So in any form of therapy, there is a little bit of hierarchy between the patient and the clinician or the therapist. No matter how much therapist try to make this as equal as possible, there's always the role of division between someone who's being treated and someone who's guiding the treatment. Having the sense of empowerment to take control over your own healing is probably the most powerful thing that a patient can have.
Installing that sense of empowerment and that trust that they're the ones in the driver's seat of your own healing process is critical for us at Enosis. By using VR as creating that space, both the patient and the clinician are visitors, and are in equal measure visitors, providing a ground where they can meet eye to eye, so the patient is no longer a visitor in someone else's office.
It's things as simple as, if you come to someone else's room, you don't adjust the lights, you don't move around the plants. You're in someone else's space, right? In VR, it is your own space, you do want to build it, and the clinician and you are exploring that space together. So it's more of a sense of going on a journey together and exploration together that VR allows.
Alana Hippensteele: Right. What are some existing barriers within current psychedelic protocols that may be mitigated with the use of VR?
Prash Puspanathan: One that we have spoken about, obviously, is the anxiety leading into the experience that come up, as the as the psychedelic experience is coming on, regardless of whether your experienced tripper, or particularly if you're a psychedelic virgin, so to speak, can be an incredibly anxiety-provoking step.
There's often that sense of like, ‘Oh, what have I done, what's going to come? I've heard so much about this experience, and just a little bit terrified.’ That's a very, very common experience. In that regard, the ability of VR—particularly a really immersive VR scenario—to buffer that internal dialogue, shut that down, because you're completely ensconced within this space. This really helps modulate not just the setting, but the mindset leading into that psychedelic experience, which is incredibly valuable.
Another thing I mentioned is that psychedelic therapy tends to exist in silos of preparation, dosing, integration, rather disconnected silos, without necessarily something to provide a thread of continuity through. Even the actual environment where you do your preparation session is likely to be different from where you do your dosing sessions. Having this VR scenario that acts as a continuous thread through the whole process, we feel is very important in sort of disrupting that siloed nature of the way psychedelic therapy currently exists.
Third thing that I might add is the way we use virtual reality as an integration tool. Integration at the moment is often once a week for anywhere from 4 to 10 sessions, depending on the protocol. Again, each session, you come in, and you're almost starting from scratch. You come in, you meet your therapist, you start having the conversation, and that session itself is building up from Ground Zero to wherever you get to by the end of that session. Using VR as an integration allows you to build on the memories from the last session, and the last session, and the last session, and the end of your actual trip session.
When I say build, I don't just mean theoretically build. For us, we create the capacity for you to actually physically build those memories and record them in your session. So there is that sense of continuity and building onto the last time that exists not just conceptually, but actually visually, even if it's virtually, and that is always accessible to the patient. That is not something that the analog system could ever do because of distinct limitations in what the analog system is able to achieve. But in the digital world, [sic] tech comes in and allows us to facilitate [that].
Alana Hippensteele: So you've addressed this a bit, but just expanding a little bit further, what are your hopes for the future of this intersection between VR and psychedelic therapy? What would be an ideal model of this technology in practice?
Prash Puspanathan: So the first thing that we would point out is that our very fervent wish is that they there is no sense of charging into this. We worry about, as I think a lot of people in researchers in the psychedelic space worry about capitalists and commercial players, well we do worry about commercial players charging into the space, and sort of wanting to deploy VR scenarios that haven't been tested, that haven't been clinically validated, that haven't been peer reviewed. We approach this very much as an academic-first team, with an academic-first approach.
So it's been vital for us to start off with putting out a conceptual analysis of our thoughts, our opinions, and our thinking that drives our methodology. Having that peer reviewed and validated, we then start to test this out in a small way, getting feedback, publishing that, and getting that peer reviewed. For us, that is absolutely vital. Because if not, you run the risk of it being overrun by commercial interests by gaming and entertainment interests, without an actual scientific process towards it being injected into therapy, and therefore the process doesn’t get adequately tested before it sort of is already there. So that's something distinctly that we would like to see happen.
The second point, I might add, in terms of the actual manifestation of it in psychedelic therapy, I think we'd like to see in this in a similar vein to the way music is used now. We've all accepted that music is an inescapable part of the psychedelic therapy process, and it helps to guide and modulate that experience. While perhaps not to the same degree in terms are being utilized throughout the dosing process, we do feel the VR has a place in the same way of helping to optimize and modulate that therapy experience and that we would love to see more people start to recognize their potential and use it as a mainstay in the therapeutic process.
Agnieszka Sekula: So the question was what our hopes for the synergies between VR and psychedelics are. I think we would like people to understand that VR is far more than just and an environmental design machine. In fact, the evolution of VR is very tightly related with psychedelics, and it has initially emerged as a state altering modality and is something that has been forgotten and has been around a little bit in the gaming industry and what we are is predominantly used for right now.
But we would like to see going back to those roots of virtual reality and psychedelics as they emerge together and to explore that. Also on a scientific level, there must be really interesting intersections of how consciousness works, or the interface of a psychedelic drug plus an immersive virtual reality environment that are both state altering.
There's the interface of a new high tech that we have developed, and we have high control over. Something that we don't really understand but has been a part of our history for as long as we know. So exploring that at a neuroscientific level and using all very powerful tech that we have now to investigate consciousness. I think this is something that could bring us much closer to understanding consciousness to understanding how sensory perception works, then using that to encourage more research in the space to inspire research that more blue-sky type of research where we don't really know the questions that we might be arriving at or some answers to put this puzzle together, not just of mental health, but of general mental wellbeing and human psyche.