Virtual Reality: Accelerating Therapy Outcomes with Dr. Howard Gurr

Introduction and Guest Presentation

Howard: My experience is that mixed reality, can make that so much faster and so much more productive. Even if we take a social situation and I say to somebody, okay, so imagine that you’re in a, bar, and imagine that there’s all these people walking around and you wanna break into a conversation. How would you do that? Most people can’t hold onto that. And so relying on people’s imaginative skills doesn’t seem to really have much weight. And that’s where extended reality and virtual reality come in.

It takes all of that away. They don’t have to do that anymore. It’s offered to them. All the information they need is given to them, and they don’t have to expend energy. It’s right there. I think that, as I said, traditional therapy takes a long time and virtual reality. Or extended reality is fast.

Bruce: to the Future of Psychiatry podcast, where we explore novel technology and new innovations in mental health. I’m your host, Dr. Bassi, an addiction physician and biomedical engineer. Today we’re with Dr. Howard Gurr, who practices VR and has a podcast in using VR in clinical practice called The Shrink is In.

He has earned two master’s degrees in psychology and has a PhD in professional psychology and a dual specialization in clinical and school psychology. He’s a certified school psychologist and licensed psychologist in New York State. He’s also earned a board certified telemental health provider certification credential through the Center for Credentialing Education.

And he practices in Long Island using primarily virtual reality. And his website is Doctors Gurr, D-R-S-G-U-R-R.com. Welcome, Dr. Gurr.

Howard: Thanks for having me. 

VR Adoption Journey: Insights on Integrating Virtual Reality

Bruce: tell us a little bit about how you use VR and how that came about.

Howard: Okay. So I’ll give you the how it came about first. I’ve always looked for ways to speed up therapy and become more efficient clinical practice and also practice management. I’ve always been using computers and technology as best as I could to complement my practice. And I came across virtual reality as a particular tool, probably around 2000. And that was because I came across Skip Rizzo’s work he had is a virtual classroom that he used for potentially the diagnosis and treatment of ADHD children, which I thought was perfect. And then I reached out to him, but he already had moved on to something else. And that particular virtual environment was sold to, I think Psych Corp.

In any case. So I kind of put that on hold and then about six or seven years later I decided that I was gonna use virtual reality for public speaking anxiety of executives. And I didn’t want to be locked into a place. I wanted to be portable. And there was only one player at the time virtually better who had a platform, but they were pretty much heavily processing and there was nothing that could be done on a portable laptop that would run their program. So again, I got put on hold, and then around 2015 I was at a conference on technology and private practice, and the presenter just kind of threw out at the very end. Oh. And there’s this company in Barcelona that’s using Samsung phones and Samsung Gear VR to elicit anxiety for phobias and using vr. And I went, wow, that’s it. And prior to that, like a setup might’ve been, I don’t know, a hundred thousand dollars and it was kind of clunky and the resolution was poor and the technology wasn’t behind it, and the software really wasn’t behind it. It was too expensive and difficult for a clinician like myself to adopt VR in my practice. So when 2015 hit and VR came out in the Samsung, platform, I jumped aboard. And so starting in 2016, that’s when I played with it for months there was really no training on how to use VR. I understood CBT I understood mindfulness, I understood stress management. I’ve worked with patients who had phobias, but I had to be very comfortable with VR to be able to, introduce it to my practice. And so that’s when I started using it in my practice. And, in the beginning, I was using it in my office face-to-face, you know, I would be sitting in my computer and the patient would be wearing a head mounted display in the office, and I would be able to get feedback. So I would get galvanic skin response or heart rate variability. So I knew physically what was going on in addition to or on top of their subjective units of distress. And then the pandemic hit. And that took out the idea of having people face to face because I wasn’t gonna do that any longer. The company that I used, the platform that I used, which is now called Amelia, came out with a remote version where I could use other people’s cell phones as the engine. All they had to buy was like a cheap head-mounted display. And they would log onto the platform and I would log onto the platform and I could control their cell phone from my office. And so we would use the cell phone as the virtual reality generator. it had enough processing speed and it had enough refresh rate that people weren’t getting nauseous and they weren’t getting cyber sickness. it was as effective in many respects as doing it in the office. And so since 2020 I’ve been doing everything remotely with my patients and I use VR primarily for anxieties and phobias. and sometimes I use it just for people who need to learn to relax and I kind of help them use the VR on their own to, just get into a much more relaxed state. I can’t tell you that every patient I have is a VR patient because they’re not. I think VR is appropriate for certain circumstances and I think that, you have to be comfortable with whatever you’re using a tool for. And so I’m very comfortable using it for phobias and anxieties. I think there are other people who use it for different things. But I’m not gonna step into territory where I’m not trained or comfortable. So VR has proven to me to be very effective in reducing treatment duration and increasing compliance. The data suggests that VR has a pretty much a 90% I hate to use the word success rate, but, you know, improvement rate I would think that the majority of my patients fall into that category. Good chance that if I work with somebody with VR, that I’ll get them to the point where they need to be within eight to 10 sessions.

Being Cautious: Navigating VR in Mental Health

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Bruce: That’s good. What do you think clinicians should be most cautious about when starting out? Would you suggest that they experience being on the receiving end as a patient would experience that environment or go through a certification training? or do you have any other words of wisdom for somebody starting out?

Howard: I wish there was certification or training, but there really isn’t anything official. There are people working on that right now, trying to come up with a, some kind of accreditation. But I think that talking about VR and experiencing VR are two different things,

I think that most of the people that I’ve talked about VR had no recognition of the power until they were actually using it. 

Bruce: Myself included

Howard: Yeah, me too. When they first, showed me the platform they went through all the VR environments and I just sat there. Yeah okay. And I wasn’t really impressed. not great with heights and I’ve had some anxiety reactions in the high places. And so at one point, the guy who’s selling me the product, demoing the product, said, okay I’m gonna put you on a glass elevator and we’re gonna take you to the top of a building and at the edge of a balcony. And I went, okay. And so I got to the edge of the balcony and he said, okay, take a step. And I said, I don’t think so. And I was in my office. I was right here. And my brain, part of my brain knew I’m in my office, I’m not gonna fall. But my other, the other part of the brain, the more primitive part brain, wouldn’t let me take the step. So I went, okay, I got it, I understand now. And so at that point, I knew that if you had some kind of emotional connection to a virtual environment, , it’s gonna show up. There’s a game called Richie’s Plank. 

And so I have that in my Oculus and Richie’s Plank is what actually, Les Post would call the low hanging fruit of vr. Because pretty much everyone is going to respond to this. And what happens is in this game, and the Oculus has six degree freedom. So this, that mobility where you’re, as you’re walking, you’re walking in the virtual environment as well. And so in that game, you’re in an elevator that opens up on the 80th floor and it opens up outward and sticking out of the elevator is a board. And you’re supposed to walk on this board and at the end of the board is a cake, and you’re supposed to get a piece of cake and walk back. And most people either "A", have significant difficulty walking on this board. Because as you’re walking the board’s creaking and you’re moving in that environment. Now I’ve set this up and I honestly, it took me like four or five times to step off the board. I want you to see what would happen if I stepped off the board. But again, my brain wouldn’t let me do that. And eventually I did. But in that game, you actually fall and then you die in the game.

Bruce: it’s a good reminder. you can’t necessarily think your way out of anxiety when it happens in the heat of the moment.

Howard: No, you can’t. No, because the brain already is in gear.

it’s a primitive part of the brain that’s already going. And the front part of the brain is slower than the rear part of the back part of the brain. So it’s always playing catch up and you just, you know, you gotta kind of like, let it process and go through. But any case, I think at this point it’s still somewhat of the wild, wild west and extended reality and virtual reality. And I think that people have to learn things by themselves. And there are companies out there that are giving training, like Amelia gives a lot of training for clinicians because they realize the clinicians have no training in vr. I think that they’re trying to establish, a training program that’ll appease and kind of. Comfort clinicians to step into that territory because, you know, obviously I think, most clinicians are not gonna, adopt a technology in their practice that they’re not familiar with. 

Necessary Skills: Expertise in VR Application

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Bruce: What do you think necessary skills are for those clinicians to start? Obviously you have to be attentive and conscientious to how the individual’s reacting, especially if you don’t have GSR Galvanic Skin Response or HRV monitor going looking to see how their body language, what that’s telling you.

What other types of skills would a clinician need to have in order to jump in?

Howard: if you look at VR from the perspective that it is a tool. And it is a therapeutic tool. It’s like anything else. So for example, you know, if someone has a fear of dogs ultimately somewhere along the line you’re gonna bring a dog into the office or you’re gonna have them exposed to a real life dog. And to me it’s the same thing except it’s virtual and it’s more comfortable because the person’s not exposed to a real dog. and if they’re overwhelmed, they just take their headset off and they’re out. I think that it probably lends itself more to a cognitive behavioral therapy approach. I don’t think, an analytic approach would lend itself to using this kind of technology so easily. And so a very basic scientific cognitive behavioral therapist, could probably step into this pretty easily. I think the problem currently is that although the technology’s been around a while, there’s several issues that need to be kind of ironed out. So when I first started doing this I’ve been keeping track of companies in the behavioral health realm, and when I first started there was probably a handful and I’m up to 114.

So there’s 114 companies in the behavioral health realm worldwide. And many of them are more focused, they’re not generalists. So either they’re dealing with dementia or pain management or autism. 

So there are all of these companies out there but the problem is that, they’re all over the place. And you can’t really, I guess as a clinician have subscriptions to all of these different platforms. So you have to pick what is gonna be, you know, your primary subscription because there’s a cost involved. And I think that for it to be clinician friendly, it has to be almost as dumbed down as possible. And everything has to be in a package and easily accessible. I don’t think we’re there yet. I think it’s still at this point, there’s a certain amount of clinical wrangling in a sense and kind of like being an innovator and thinking outside the box, even in vr. So for example, any package would have generalized computer generated environments. But what happens if someone has a real specific problem?

A program might have a highway or a street in terms of driving, but if someone had, let’s say a particular problem in a particular location and you want to bring them there, we used to be able to do that with Google Maps or Google Earth. And then, we were able to do YouTube three sixties videos that were very specific. People have shot videos of the Long Island Expressway from one end to the other. And the LIE is a disaster of a road. And if anyone’s gonna have a driving phobia, it’s gonna be on that road. I was able to download a section of the LIE and put that in the Oculus where the person was now experiencing the area that they might have difficulty

Bruce: Just a straight video, not like an immersive video

Howard: Right, But, but it was a 360 video. We’ve lost that capability now.

Bruce: they look around and they’re looking at the top of a car 

Howard: or some people shot of an inside of the car, you could hear the radio on some of them. You have to think outside the box as a clinician and unfortunately, we’ve lost that capability very recently because Google is no longer supporting that. So we have to find another way to get 360 videos that are suitable to exposure therapy. I actually have a 360 video camera, but I don’t like the product.

It’s not as clear as I would like. What I did once was that I got my dentist to agree that I could use his dental operator and I had one sitting in his chair for people who have, dental phobias I’ve never used it but it’s there.

360 Videos VS Metaverse Environment

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Bruce: There’s gotta be a company that will eventually allow you to upload 360 video and then allow you to layer that into a digital mask so that way you can modify certain variables like the lighting and the sounds and the, or not somebody comes in the room and, things of that nature

what do you think is the advantage , or maybe not advantage, but difference between using that 360 video versus an immersive digital, metaverse type of environment?

Howard: You could look at VR from, in terms of therapy from, two different perspectives. One is the therapist is outside the VR environment. Directing. And the other is the therapist is in the VR environment with the patient. There was a company that no longer exists that I used in which I could be an avatar and the patient was an avatar in the same environment. I would’ve somebody who had difficulty dancing with bridges and the entire visual experience in front of us was a 360 video of the George Washington Bridge. And he and I were, would be sitting there talking about his experiences and his feelings as two avatars. I think ultimately that’s where we’re gonna have to wind up.

I think that some kind of. Combination of augmented reality and virtual reality. Mixed reality, has to be there because, I think that the clinician and the patient should be in the same place. Here´s my ultimate dream, Star Trek two had the holodeck, which was their place to go for relaxation and rest, but basically what it was, was an empty room and you programmed exactly what you wanted. And so one show these guys decided they were gonna go to an 1800 saloon, and they, dressed up in cowboy garb, and they walked into the saloon. And the saloon was populated by, Very realistic AI avatars who they interacted with. And so you couldn’t tell really when the program was running, who was real and who was an avatar. 

And that’s my ultimate dream because ultimately at that point I could set up an environment and to create anything and be able to, work through whatever the patient’s experiencing because I’m right there coaching them through.

Bruce: So in your mind, you see a distinct advantage of having an avatar and whether or not the avatar is extremely realistic versus . Kind of more 2D computer generated, cartoonish type of looking thing is to be discussed. But you think that it’s advantageous to have both in partnership working through environment?

Howard: I would like to be as realistic as possible. I think that makes the most sense to me. but my experience was that initially being an avatar is a little unreal.

But the more the avatar mimics me and my motions. In my movements and, my experience and my face, the more you lose that distance, the more you become immersed and you have that sense of presence in that virtual environment. cause I think right now, for the most part, I’m like a disembodied voice to my patients.

They’re in a virtual environment. I’m not, I mean, I’m seeing what they’re seeing, but I’m not in their environment. And now I’m talking to them and I have, I’m like this voice that comes outta nowhere. And I think that that’s potentially, negatively affecting that sense of immersion and presence.

Tailored Exposure Strategies

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Bruce: Let’s explore this topic a little bit more because I think some people . Might have varying opinions on this,

When ultimately what we’re trying to do with exposure is prepare them so that they can take on that experience on their own independently. So whatever we could do to essentially mimic them, being able to, walk through or handle that experience on their own, seems like it would be closer or as close as possible to the ultimate holy grail of what they would be doing.wonder if there should be a setup in which, kind of like underlying the whole premise of exposure therapy, the first one is with you there, present with them, and then maybe eventually as like step two or one of the later steps, become that disembodied voice that only really steps in. When you notice their suds go up or quantitative measures of distress increase so that it’s possible, maybe there’s even a hybrid approach that could be most suitable for patients. Rather than one or the other is better than the other.

Howard: I wouldn’t disagree with that. I think you’re right. But I think it’s important to be able to, I mean from beginning to the end as a clinician, I want to have my fingers there. I don’t want people experimenting on their own so much. I mean, I would definitely pull back, be in a distance or even outside the environment and watching what’s going on. To me, most things require practice and skill sets. we think of social skills as learned as natural, but I see them as learned behaviors. I think that there are people out there who don’t have the skills, either they weren’t trained or they weren’t available or, whatever else is going through their lives at the time.

They didn’t develop the appropriate skills to handle things that would be in a mature and healthy manner. And so I think that as a clinician, it would be my responsibility to get them to the point where they have the basic skills and then build on that and allow them to blossom and be more successful. But 

I think my experience is that, mixed reality can make that so much faster and so much more productive. Even if we take a social situation and I say to somebody, okay, so imagine that you’re in a, bar, and imagine that there’s all these people walking around and you wanna break into a conversation. How would you do that? Most people can’t hold onto that. And so relying on people’s imaginative skills doesn’t seem to really have much weight. And that’s where extended reality and virtual reality come in.

It takes all of that away. They don’t have to do that anymore. It’s offered to them. All the information they need is given to them, and they don’t have to expend energy. It’s right there. I think that, as I said, traditional therapy takes a long time and virtual reality. Or extended reality is fast. 

I would say about a third of my patients come from other clinicians who are seeing patients. And in the process of the therapy, somewhere along the line, the patient says, oh, you know, I haven’t flown in 20 years and I have to go to my brother’s wedding or something in six weeks and I’m freaking out. what would happen is that clinician would send them to me and I would spend the next five weeks working on their specific phobia. And I don’t wanna step on anybody’s toes, so I don’t really delve into a lot of other things. I’m very focused, here’s what I’m gonna fix for you, and in six weeks you’re going on that plane, and then they go back to the therapist and work on whatever else they’re working on. but I think that’s something that couldn’t have happened without the advent of VR and extended reality. 

Working With VR Environments: Insights into Practical Implementation

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Bruce: can you speak to the generalizability of, a VR environment to the patient’s, ideal or native environment that they are wanting help with? Because I think one of, often criticism I hear of is that we didn’t have this environment, this, not this environment. To what extent does that apply, because I know for public speaking, don’t need to be in the auditorium in order to learn those skills for public speaking or for flying.

It doesn’t have to be the, exact model of the airplane with the, particular layout that you’re going to be in. How does a clinician or patient know, to what extent do those skills generalize to the environment that they’re looking for help in?

Howard: I think that’s a very important. Distinction that has to be made. It’s not necessarily always the environment that somebody comes in with that they’re concerned about. Because we know that, for example, in terms of anxiety reactions and panic reactions, it doesn’t matter what the environment is.

If it elicits, a panic reaction, because we’re working with that, we’re working with the amygdala and we’re working with the sympathetic nervous system. And what we know is it’s gonna kick off regardless of what the situation is. If someone has an anxiety reaction, so for example, I may have someone come in and they have fear of driving. But let’s say the driving phobia doesn’t really elicit enough anxiety for me to work with, so I might put them on the edge of a building. And I know at that point they’re going to elicit, they’ll say, well, I’m getting very anxious. And we could go through all of their symptomatology and we could work on practicing how to diminish, reduce, or even shut off the panic reaction in that environment because I know that if you have the skillset to do it there, that generalizes to any other environment that is similarly evoking that kind of anxiety.

 Empowering Individuals in the VR Therapy Journey

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Bruce: Do you have to educate patients on letting them know that? Because I feel like when they go into the first one, they’re probably like, you know, this is not my situation, doctor, you know?

Howard: Yeah, I do educate them and I think before they step into any virtual environment, I spend a lot of time, educating them on, the physiology, the psychology, the behavioral issues. The biology responses. so I educate them on what panic attacks are. I educate them on what cognitive behavioral therapy is in terms of cognitions affecting behaviors. we talk about everything before they step into a virtual environment. And I will tell somebody, listen, you know, this isn’t really eliciting the anxiety level we need to work with, I’m gonna put you somewhere else. And in all honesty, I have not had one person who only had one phobic reaction. they might come in and say, oh, I have a fear of flying. And I’ll go, okay, great. And what about this and this? Oh, I’m not good here either you know, but that wasn’t their problem. They didn’t come in with that. But you could hear that, you know, that anxiety because anxiety generalizes that, you know, it’s over here. And then we have the what if it happens over here? And what if it happens? And the next thing you know it kind of builds and becomes more global. So everyone who’s come in with a phobic reaction has another, at least another phobic situation that I could work with. So they’re educated and I want them to know exactly what’s happening to them, exactly why it’s happening, because I want to normalize it for them. And so, you know, what we know is that panic reaction is really the brain kind of shortcircuiting in a sense. And reacting in a defensive manner at the wrong time, in the wrong place. And then it tends to generalize. So if I teach them this is not your fault and all the time that you’ve been trying to like reason with it and do traditional therapy, it hasn’t really worked because the back part of the brain is too fast and you’re playing catch up all the time. And so let’s work with what we have and by teaching them to recognize their body signals. And to recognize what’s happening with their breathing and their posture and their muscle tenseness and tightness. You teach them all these things, it’s almost like, wow, nobody ever talked to me about this. But because that’s there, once they walk into a virtual environment that’s anxiety provoking, they at least have at least one skill already. and it gives them the ability to understand that, oh, I, can control this. I’m not completely victimized by this. I can change this. I just think it’s something that everyone should be doing in the clinical field because it just makes so much sense. but I understand, you know, the roadblocks for people 

Patients With Hypoglycemia: Special Considerations

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Bruce: In your interview with Les I think he brought up the topic of how, you know, with hyperglycemia and hypoglycemia, sometimes when people are starting off dealing with that disease process, don’t quite understand the subjective experience and how it correlates with that number. But eventually, as people get further and further along and they’re understanding how they feel at this number and how they feel at a different number, they can, more quickly identify when they’re becoming hypoglycemic.

And that is like a very nice analogy for how I can understand, the galvanic skin response or heart rate variability is not something that we, it’s ingrained in our consciousness as to, how to correlate with our experience, nonetheless, with time, that’s an additional benefit people see.

Almost done, like a biofeedback type of manner. how do you work through that with patients? Is it well incorporated into your sessions with them in looking at the number.

Howard: From a distance standpoint, in terms of doing it remotely, it’s very difficult to use those measures. So we’re stuck with subjective units of distress. and there are people who are working on, tools that you could add to the, head mounted display that will do measurements, and give us feedback even remotely. But what I’ve done is, you know, there are enough commercial heart rate variability products out there that people could buy. So even like an Apple Watch has an HRV component and Fitbit has it, and their other ones. And so I, suggest people get these devices on their own so they could monitor their heart rate variability and kind of get that sense of what their body feels like when they’re tense. Because I, think it’s important to, educate them on that. and to me it’s like, know, not everything is psychological. I think people have to understand that. That there are physiological things that happen. And then the psychological component is secondary. Because we kind of try to develop techniques and strategies to handle what we don’t know. So for example, I was talking about patients who came in who would say stuff like, I’m depressed and I’m sad and I’m, and I have no energy. And there’s no reason in the world why that’s the case. There’s nothing going on in my life at all. and I would say stuff like, have you noticed your skin’s dry or your hair’s dry? odd question, but, would say, well, yeah, a little. And I would say, okay, then you know, I need your thyroid checked. Because there’s a good chance, maybe it’s not psychological, it is physiological. And probably over the last, you know, 35 years or so, two or three people really did have thyroids that crack out. And they needed medical treatment. And after the medical treatment, they come back and they go, you know, I feel a lot better. Okay. you’re done. but I think that people think, oh, it’s psychological, it’s, and they get anxious and they become self, critical that there’s something wrong with them. when it comes out, it’s a biological issue somehow, they’re not as critical about themselves any longer because, it’s not unnatural. So a lot of phobias and anxieties are fueled by, things that are just biological or on some levels, we know that genetically there are predispositions and certain people will, inherit, I call it hair triger, so to speak, that some people are just build anxiety up, you know, real quickly. And other people are completely insensitive to it. And it’s just the way your packaging is.

But I think when, even when you do that and you explain to people that it’s not your fault, it’s just, you know, the hard wiring, it takes some of the stigma away.

Restrictions: Understanding the Limits of VR

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Bruce: Let’s talk a little bit about the harms associated with VR and not the harms associated with doing exposure therapy. Obviously, if somebody’s not educated on that and is doing it incorrectly, there can be harm done to the patient. But VR headset itself, I’ve heard of being possibility that it could triger dissociative reaction individuals with trauma or make a render psychosis exacerbated by the VR headset.

I think there’s some variability of opinions here, and I’d like to kind hear your take on this, but are there any absolute or relative contraindications for using a VR headset or even the goggles or the device that would use your phone as a mount?

Howard: I have restrictions in terms of the patients that I take. doing it remotely makes it even more tenuous because you’re not there with them. So, I don’t take patients who have psychotic episodes, suicidal ideation. Epileptic seizures or significant neurological disorders. I think I was also in the beginning concerned about like borderline personality disorders, but that’s cotton. I’ve loose on that one.

I’ve had people in the past who couldn’t wear the head mounted display for more than a minute. And, you know, VR definitely wasn’t for them.

Bruce: And tell me more about suicidal ideation for individual using VR headset.

Howard: I don’t think the VR headset promotes it. I just think that, it’s too uncontrolled, I think to do therapy remotely with people who’ve had suicidal ideation, serious suicidal issue. 

but in terms of side effects or difficulties? I haven’t had any, other than I’ve had a couple of people who’ve had, vertigo in response to, you know, motion in the vr. I had this person who couldn’t deal with the driving because the motion got to her. but most people get used to it, and I haven’t had any, real negative effects that were concerning. But as I said, I have a very narrow Population that I pick. and there are other people out there who are working with schizophrenic patients in vr or psychotic patients in vr. but I think most of those people are working in institutions that there’s a team working with them not a solo practitioner like myself.

Bruce: Are there any ethical concerns that we should be on the lookout for other than data privacy issues? 

Howard: Data privacy issues is the big one. I think it’s the only other concern I’ve ever had really is when you give somebody the access to using the VR on their own. like in the platform I use has about 13 or 14 virtual environments that You could use on your own without the therapist. and my concern is I know who I’m dealing with. but what happens if a patient turns it on and says, oh, you gotta try this to somebody else.

I don’t know who that person is, I’m always concerned that where there is someone toward effect to somebody else who I don’t know because they were using the VR environment that was designed for somebody else. 

And I also think that, at this point, there aren’t like clinical therapeutic virtual environments that are handed out to patients to use on their own. It’s mostly just the relaxation and mindfulness and the stuff that’s not threatening because there’s a concern of people, you know, re-traumatizing themselves. 

you know, without a clinician being present, I’m always concerned that somebody just ,puts themself in an environment and now they’re creating more anxiety

Insurance and VR Therapy: Addressing Challenges in Reimbursement

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Bruce: have you heard of any insurance reimbursement issues that any patients have had? 

Howard: my answer is no. I know that that’s really a big question. but in terms of therapy, it’s the same CPT code. If I’m doing exposure therapy, it’s exposure therapy. the fact that I’m using virtual reality as a tool, that shouldn’t really negate anything. And so my experience is that I’ve been, reimbursed a hundred percent of the time. and just to give you a story of the circumstance, there was a person who came in and I wasn’t on their insurance and they really needed help and they really didn’t have enough resources. So I agreed to take a single case contract for that particular person. And when you do that, you have to show that you are, providing a service that panel doesn’t have. so that, you know, they could say, well, you’re outta network. And so, you know, why would we agree that have you contract with this one patient when, you know, there’s several other doctors in the area who do exactly the same thing. And so I had to speak to them and tell them exactly what I was doing. And I was using VR with this patient and they were like thrilled about it. 

And they said, oh, great. And I got approval. So I’ve never had an issue as a clinician doing therapy where reimbursement was a problem

Tech Progression: Exploring the Dynamic Landscape of Therapeutic Innovations

Bruce: I want to touch on The future of VR in clinical practice, and talk about the trajectory of where all of this is headed. And obviously the name of the podcast is The Future of Psychiatry. We wanna talk about what is possible to come and make steps, take steps to prepare that. there’s, a lot of use of AI to, clone individuals’ voices.

I’m sure that this technology is going to really accelerate quite quickly in terms of its customizability to patient situations. I think eventually you’re going to be able to just type in a environment that you’re desiring and that can immediately be the environment that the patient is put into and it could just be a completely artificially generated.

what types of issues do you foresee in the future? that you’ve heard of or speculate could potentially happen? 

Howard: Well, interestingly enough, there’s a company in Norway called Simile that is working with social anxiety and AI I’ve played with their platform as well. I thought it was absolutely amazing. The AI characters are not scripted. they only respond to what the individual in the virtual environment says. And so you could say anything to them and they come back with a relatively, coherent related response, it was unbelievably impressive. So in response to AI, I actually think that, AI and VR and extended reality, it’s all gonna come together soon, and I think it’s gonna be a very comprehensive package where the virtual environment is really interactive and individualized to the patient’s needs. But, in terms of concerns, I think clinicians have a concern that these kind of platforms. Are gonna diminish them and that it’s going to jeopardize traditional clinical therapy and there’s gonna be this void, and significant distance between patient and therapist. And it’s gonna lose that kind of, integrity that therapy has now. And my sense is that is not gonna occur. I still think clinicians have their place and their, spot that they need to be in because therapy really, you know, much of therapy is a relationship between the clinician and the patient. And I don’t think we’re gonna lose that, but I think that they have to be comfortable with the idea that virtual reality and technology and AI, it’s going to come into clinical practice. And I think that. Down the road, technology is going to, you know, become more and more involved in what we do as clinicians. and I think that you can go back, when I, first started, I opened up my practice in 1983 we used to do billing by NCR Paper. In other words, you wrote the bill on the NCR paper and you, tore off the second sheet and you gave that to the patient. And then the first sheet, you know, either went to your, file or, you know, you attached it to an insurance form. And that’s how everyone did their billing. And then in 1990, I came across this package to, electronically produce my bills. 

And I would say, well. How long does it take you to do your billing every month? And I’d say, well, I dedicate a Saturday doing my insurance billing. And I would say, well, I, spend five minutes. And I said, the biggest problem I have with my billing is I don’t like folding the paper, to put it into the, envelope.

that’s my biggest time consumer. and people say, wow, that’s amazing. You know? but nobody was stepping into that territory because it was so, you know, difficult. And then, 1999, I had a website. I had my first website that I created, I used publisher 98. They had a module for webpage. And at those that point, we had dialup. we hear all these tones, VP and, I had this company in California, it was 1999 for Dialup, but 24 95 if you wanted a webpage. So I created a webpage and nobody else thought that was something that they ought to do. And of course, everyone has a, website. And then I told you in 2006, I did podcasts. Nobody was doing podcasts. But all of a sudden everyone has to have a podcast. I think that technology takes its time and it kind of intrudes in a sense, and, starts appearing in our practices. Even the concept of teletherapy. I mean, teletherapy has been around a while, but nobody saw it as really meaningful until the pandemic hit. And now all of a sudden, oh, it really works. Yeah, well, of course it really works. six or seven years ago I got this, board certification in Telemental Health, and all my friends are looking at me going, what are you doing that for? What the heck do you need that for? And I go, we’ll see, you’ll see. It’s gonna be worthwhile. And of course it was. But I think technology takes years for it to get involved and enmeshed in clinical practice. And, you know, the rumor always was that it was, it takes 20 years for technology to become, widely accepted in clinical practice. And I would say that, even though virtual reality’s been around for 30 years or so, actually longer if you really want to get at it.

But, in terms of, you know, behavioral health 30 years, I think we’re at year seven. And so I think it’s gonna take a whole bunch of more years, 13 years or so for all of a sudden everyone to be using this kind of technology. But at that point, the technology should be sophisticated and easy

I mean, think about, you know, the idea of a cell phone, cellphones came out. I think my first cell phone was a, OKI 900. it must have weighed a pound.

this was, it was a brick and I had it in my pocket, and we keep my jacket down. it was so heavy. it was a dollar a minute or any portion of a minute. So if you talk to someone for 61 seconds, that was $2. I was like walking around with this thing and no one had a cell phone. No one knew what it was. And now I leave the house without my cell phone. I feel naked. You know, where’s my cell phone? Cell phones have now become so integrated into our world that, you know, we just accepted it as just natural. That hasn’t happened with virtual reality yet. There’s no, compelling reason that everyone should have a VR headset. but when that day comes, this’ll just be part of what we do. 

Bruce: Yeah. Going back to what we talked about originally, think part of the slow adoption is the fact that right now the consciousness of the public it’s associated with gaming primarily, and geeking out a little bit. It’s not like a typical thing that most people use for industry or for productivity or, writing a Word document, you’re not put on a head a virtual reality headset for it.

It’s not as ubiquitous as the computer screen is, or a cell phone is in doing those tasks. And once people realize how it doesn’t take much to feel immersed in that environment then eventually it’s gonna start to reach that critical mass where takes off exponentially.

Howard: Unfortunately, I think it, normally technology starts up top and, and kind of filters down to the general population. I think this is the reverse. I think it has to be ubiquitous and everyone has to have one. And then it should start becoming more, I think, accepted technologically speaking. And so we’re not there yet. And I was hoping that when Apple, entered the realm, you know, ’cause Apple kind of like sits back 

And watches everyone screw up they figure out, okay, we figured out where that problem is. And when they entered the fray so to speak, I was like, ah, it’s great.

Because once they’re in, they simplify everything. I think they only jump in when they figure there’s a market for it. Okay, great. That’ll turn everything around. Now obviously the first iteration is not gonna turn everything around you know, figure $4,000 for a device that’s not happening, but maybe about a second or third version, it’ll become cost effective enough that enough people would pick it up. And I think once that happens, Then the development of usefulness will start to really blossom. So at this point, you can do meetings, you could talk to people from anywhere in the world. You could play some games, whatever.

But the games are not compelling. And the people, you know, the kids that I have who have VR headsets, they’re thrilled for about a month maybe, and then it winds up in a closet somewhere. It´s like, you know, all right. It was fun. But my, PC or my Sony works so much better or my Xbox, I like it so much better because, that’s what they’re used to. and there isn’t a game that can keep these guys going forever and ever. Maybe when there’s enough money involved and enough of a return on investment. Then a lot of companies will start investing into, extended reality. And then I think it’s gonna take off. And when that does, and everyone seems to have one and it’s ubiquitous, ’cause every household has one. The idea of using it clinically might make more sense to people, because, you know, now they know what it can do. And since everyone has one, it’s gonna be easy. And I think technically speaking, there’s a problem currently with onboarding and getting people to, side Quest your Oculus to get a program in there that wasn’t on, the Oculus store. Most people aren’t gonna side Quest their device. And of course the Oculus one was a little bit more, I guess prone, to be monitored and wasn’t very secure. So subsequent models were, and even if they had enterprise models, but the enterprise model’s like $800. And so who’s gonna buy that? when everything becomes more easy to use, then I think larger institutions will also pick it up, and, go back to your early question about insurance. FDA approval has to be there. I think for institutions to take the risk of investing in VR or extended reality in clinics, because, they´re gonna have to buy equipment, they’re gonna have to have a staff that’s gonna monitor and manage.

They’re gonna have to train their people. And do I get my money back on that? At this point, the answer probably is not enough. 

But I think that somewhere down the road that’s gonna be a more financial rewarding. Venture for them. 

Expanding Horizons: VR Therapy Across Varied Disorders

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Bruce: are you excited about any other treat types of disorders for using, virtual reality to treat other than anxiety? I know that’s what your primary focus in your clinical practice, but say, communication disorders like in autism or depression psychosis even. I’ve heard of people trying that or even chronic pain.

Howard: yeah, I like the idea. I think social anxiety is a good one, specifically, but I also think that autism is really a good avenue. and pain management is great. There are people using it for substance issues as well. So I know there’s, a program out there for smoking cessation, and there are people working on Substance issues in terms of stimuli to elicit substance drives. Bar scenes or social scenes or places where, people would have a trigger of some sort that might set them off.

I think that there’s all sorts of avenues that are out there. I like the idea of, dementia patients and, patients who are in nursing homes, just to give them the ability to travel virtually, have experiences that they never experienced before. I think that there are tons of populations that would benefit from the intervention of vr. 

Hey, that’s, there’s 114 companies out there. They’re all doing different things. I think that eventually, as in any industry, there’s gonna be some major players and then a lot of other people are gonna fall by the wayside or merge or get bought up. And we’re seeing that already.

We’re seeing companies merge. So Amelia merged with XR all these companies are gonna have to like, come together and, offset each other. And with the development of the technology, I think we’re gonna see some great things down the road, in terms of behavioral health and mental health. 

Bruce: Well, it was a pleasure talking to Dr. Howard Gurr, a VR trained psychotherapist located in Long Island and podcast host of the Shrink is Inn. I appreciate you coming on the show. 

Howard: Well, thank you Dr. Bassi. I had a great time you’re doing a great service here, so keep it up.