Virtual Reality Advances with Dr. Kim Bullock: Techniques and Innovations

Introduction and Guest Presentation

Kim Bullock: I could see with augmented reality that people could practice their discarding in their real environment, then be able to do that. You know, people with phobias who are afraid of spiders could be in their own home, in their environments where the fear is really maladaptive. And, you know, bring the spiders on. I think it’ll just add flexibility to the simulations that we can do and make them more realistic and maybe more applicable to their problems.

Bruce Bassi: Welcome 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 are with Kim Bullock. Dr. Bullock is the founder and director of Stanford’s Neurobehavioral Clinic in Virtual Reality and Immersive Technologies program. She’s also a leader and pioneer in telehealth services using XR. She has published many peer-reviewed articles and is a Cambridge and Oxford press author on the subject of functional neurologic disorders. Her primary clinical research interest is exploring the use of technology for trauma treatment and psychiatric illnesses involving the disruption of bodily perception and function. She’s currently focused on the use and dissemination of immersive technologies in telepsychiatry, as well as its use in the augmentation of physiotherapy, psychotherapy, and skills acquisition. She’s also the host of the podcast called Psychiatry XR, which is specifically dedicated to utilizing VR to treat psychiatric illnesses and has explored various topics such as virtual body ownership, body transfer experiences, chronic pain treatment, and utilizing wearables. So if anyone is interested in that, check out Psychiatry XR. I feel really lucky to have Dr. Kim Bullock on the show. Welcome.

Kim Bullock: Oh, thank you so much for having me. Yeah, I feel lucky to be here.

Beginnings of VR in Mental Health

Bruce Bassi: We have very much overlapping interests. My interest is in any sort of technology that is pushing the needle forward in our treatment. I feel like virtual reality is so underutilized mainly because people don’t know very much about it, but once they try it, they’re a believer immediately. I know you have an interesting story as to how you got involved in it. It seems like you’re a believer now as well. Could you tell us a little bit, briefly about how you got involved, and then we’ll jump right into all your wisdom in utilizing VR to treat psychiatric illnesses?

Kim Bullock: It actually started back in my undergraduate days at UC San Diego when I had Ramachandran as a professor. He was a neurologist, physician, and perceptual psychology researcher, and taught about the rubber hand illusions and mirror therapy that could amputate phantom limbs. That class really got me interested in going to medical school. It didn’t seem boring and it seemed relevant. It came around that after I did my medical school training and psychiatry training, I ended up researching the diagnosis that’s kind of at the interface of psychiatry and neurology, which is functional neurological disorder, used to be called conversion disorder. Also, the roots of psychiatry come from that diagnosis. And then also ending up combining perceptual illusions as a possible treatment using virtual reality, kind of an extension of Ramachandran’s initial research. That’s kind of how I got into VR. We did a trial to enhance physiotherapies for our patients with functional neurologic disorders. We were doing groups, but they were having trouble getting access to physiotherapy, and it seemed like we didn’t have enough somatic interventions. So we did a trial of mirror visual feedback on them, and that’s how I got involved with VR because we had a virtual human interaction lab at Stanford with Jeremy Bailenson. They were trying out mirror therapy for chronic pain, so they helped me try it out on some patients with functional neurologic disorders, and then we did a clinical trial and some cue desensitization for people with triggers to their psychogenic movement disorders using VR. So yeah, that’s kind of how I got into this, but I kind of pivoted into anxiety disorders in our clinic as well. Still, half my practice is functional neurological disorders.

Challenges of Psychiatry with VR

Bruce Bassi: Well, you’re attracted to challenges by nature, it sounds like, and you’re attracted to one of the most difficult to treat areas within psychiatry. It’s really not as straightforward treating a functional disorder as something like a phobia of going over a bridge. How do you go about utilizing VR to treat conversion disorder, psychogenic seizure, functional abdominal pain? Where do you start?

Kim Bullock: I wasn’t sure that you could, but you’re right. I’ve been called an early adopter, but I think I’m an adventurer. I come from a long line of people with addictions, including myself. So we probably have some dopamine addiction to challenges. I think it’s just my Viking roots or something. I like being on the edge where there’s uncertainty. We were not sure whether virtual reality would actually help people with functional neurologic disorders, and it’s still being studied. It hasn’t been established yet. So we did a pilot study of mirror visual feedback, which is for unilateral motor and sensory symptoms, to see if those would improve with mirror therapy. And there seemed to be a little improvement, but actually, we added cue desensitization, and that seemed to be the most effective for people with functional disorders. Um, could desensitize to their cues, for some people. Going through a narrow hallway or something has them buckle their knees. A lot of this is also connected to PTSD. If somebody only has symptoms in large settings or a sports arena, we could simulate the sports arena and have them practice going to the sports arena over and over, not avoiding it. Then, eventually, the symptoms would abate. But again, it’s not an established, we haven’t done a randomized controlled trial, so we’re not using VR for functional neurologic disorders in anything but research still.

Treating Addiction with VR

Bruce Bassi: Let’s talk a little bit about treating addiction with VR. Obviously, people, places, and things. That’s one thing that’s often mentioned as an addiction psychiatrist is through those triggers that lead to a craving. Essentially, it’s almost like a similar response that anxious folks get when they’re triggered by something. It’s like the amygdala or any sort of deeper part of the brain starts to take over, and they start acting on impulsive urges that they’re not necessarily thinking out with their prefrontal cortex. So I’ve heard of VR being utilized for walking into a bar or walking by a bar and things of that nature. Could you tell me a little bit about your experience with utilizing it for addiction?

Kim Bullock: Yeah, well, I’m a certified DBT therapist, I’m a radical behaviorist, so I think everything is a behavior. An urge to have a drink, using a substance is a behavior, having an emotion is a behavior, a thought is a behavior. And everything is conditionable through classical and operant conditioning. There’s been a lot of work outside the United States in using VR for addiction. Personally, I have not used it in our clinics. Occasionally, I might use some VR for cue desensitization so we can simulate being somewhere else that might be a cue or a prompter for urges or for not being able to refuse a substance like a drink. Xavier Paler from Amelia, that’s my favorite platform. I don’t have any conflicts of interest, unfortunately, with them, but they seem to be the only platform that’s really ready for primetime, and they have some cue desensitization, like being in a bar and practicing refusal skills. So I think that interpersonal skill of being able to observe your limits, communicate limits, and say no, or just to desensitize to some of the prompters that cause urges and behaviors is super important. And then, there’s emotion regulation skills that you can teach folks that struggle with habits and addictions, involving distress tolerance and relaxation skills, mindfulness skills. So often we’ll do that just for kind of emotion regulation or be able to urge surf and things like that. Again, I’m not an expert on addiction, and I don’t see too many people with addiction come through my clinic.

Acceptability of VR

Bruce Bassi: There’s also an accessibility challenge with the resources available to utilize that and maybe finding the appropriate therapist who knows how to do it. But you mentioned acceptability, which is understanding why VR would be beneficial and why therapists’ efforts maybe out of their way to get the VR system set up and convincing a patient and talking to the patient about it and training themselves on how to use it and training the patient how to use it. Why all of those things are valuable and important in the long run in treating that patient, that’s just off the top of my head. What have you seen as the challenges in the acceptability of the VR system?

Kim Bullock: Yeah, we see much fewer problems with acceptability from the consumers, but it’s the providers, and I don’t think that we know why, but my guess is it’s a training gap. So if you don’t have it in a training program, you don’t have standards, you don’t have best practices, people are going to be not as trusting. And it’s novel and it’s new, and it takes a long time for people to change. And so I do feel like it’s basically if we could get it into the training curriculum and standardize that and maybe through the ACGME or something, then I think it would be a no-brainer and it’s not even very expensive to add to your practice. You know, a subscription is less than a thousand dollars a year and probably would have a better flow and it’s good PR for people in private practice. So I do think it’s just a kind of psychological thing that if not everybody’s doing it, I better not do it. The novelty takes a long time for behaviors to change.

Telehealth Stereotypes

Bruce Bassi: That’s a good point. I’m almost seeing some parallels to the adoption of Zoom. Just a few years ago, everybody thought this telehealth was kind of dangerous and maybe not the thing to do and interfere with treatment. I’ve gotten the stereotype that a telehealth doctor is really not as thorough or knowledgeable. They’re like, probably cutting corners. You saw a telehealth doctor. They probably didn’t really talk to you that much. I’ve gotten that a lot. They’re like, you need to see somebody in person. Like as if that in-person was better than the telehealth person.

Kim Bullock: Yes. So it’s strange how we all resist change.

Bruce Bassi: I don’t know if any of that stigma is carrying over into the VR world, it’s a little geeky because of the association with the gaming world and things of that nature.

Kim Bullock: Yeah. There’s some stigma with that. Definitely. And then people think if you do VR in practice, you are just an avatar. You and the patient are an avatar and you never really see the patient. Like the whole thing is automatized into a virtual world, which isn’t true. You know, when you see patients, if you do CBT, the amount of time you might do imaginal exposure is like 0.1% of the whole time that you do therapy. So the VR, you bring it in as a tool. It’s like a Kleenex box or a fancy chair you might use. It’s not the whole treatment.

Use of an avatar in using VR for mental health

Bruce Bassi: Let’s talk about the avatar idea because I’ve heard a kind of mixture of things from therapists who are using VR. I’ve heard one person say that, you know, the avatar idea where you’re embodied through some sort of digital representation takes away too many elements of that interaction. And I’ve had another therapist who said kind of the opposite, where they would support that because it would allow the therapist to work together in that digital space with them, gain familiarity with that environment. And then kind of removing yourself before you become that disembodied voice in just coaching the individual through the virtual space, you want to work with them through that, as if you would in real life. I’m trying to get a bit more guidance as to which way is necessarily better or what should be the recommendations for individuals starting out, or considerations even, like, if I’m going to be using an avatar, I want to think of X, Y, and Z with my patient.

Kim Bullock: There are different ways you can incorporate avatars so a patient can have an embodied experience and be an avatar in an experience. They’re not only just doing head tracking, but they’re doing body tracking. So that does require some expensive hardware still. Some people have it at home, or we used to have it when we had our therapy in person. I would have a Vive or something in the office, but we’re not using that very much. Then there’s the new idea about having the therapist come into a common space and also be an avatar and kind of meet up in a virtual space with the patient. So that’s more experimental. I don’t think we have much data about that, and it’s more complicated to do. So there’s even more barriers both for the technology that a provider would have to have and the expertise and the acceptability. I see that as coming down the line, but I don’t think it’s advanced. We don’t know enough about it to really deliver it yet in that format. But I guess telehealth itself could start to be Avatar driven. I think with this holographic videographic quality, that’s coming that we’re probably not even gonna need to be a cartoon of ourselves. There’ll probably be holograms of ourselves that will that.

Bruce Bassi: Even Amelia’s setups or environments. They have an avatar that’s driven by a computer and it has kind of like moving in a way that looks a little unnatural. I don’t see why it would be a disadvantage or a drawback to have a person in the digital environment with the patient and have it maybe look a little bit more realistic and have their body be more real-time reactions to what the patient’s saying and doing.

Kim Bullock: The technical barrier would be like, you also wanna be watching the patient to make sure they don’t fall or something. So if you’ve got a headset on too and they’ve got a headset, there’s also some security concerns. So I think it would be complicated. You might need a third person or something to make sure, you wanna also be knowing how they’re doing in real life. And if you’re both in a virtual world, you’re losing some real life. Maybe with augmented, layered kinds of realities, you could do that. Where you could be both in there, but also seeing the patient. But my concern about that at this point is when they’re fully immersed, just wanna make sure they’re safe and they’re not running into something or they’re not gonna fall or something. I think there’s just a technical barrier right now, but yeah, I agree. It would be great to I could see all sorts of uses to be in there. And think psychosis too, they’re really using that in their paradigms, in the research paradigms really well. and helping people both desensitized to social interactions and they can control the kind of social interaction, with the therapist embodying controlling an avatar. Maybe that would be more of a workaround is like, you’re not actually embodied in there, but you could control another avatar that’s in their space. So they’re able to reappraise, and also have distress tolerance, people with psychosis. And I think there’s a lot of room as well for the executive retraining and using VR and gamifying it. ’cause I hear it’s really boring to do.

VR for Executive Retraining

Bruce Bassi: What is that term? Executive retraining.

Kim Bullock: For psychosis, cognitive enhancement therapy, sorry, maybe I’m saying it wrong. You know, building brain capacity computer exercises, been shown to help cognitive functions, ability to organize and things like that for people with psychosis. So being able to translate that intervention into a VR therapy it could gamify it, make it more fun, make it more interactive, there’s a lot of potential for that.

Bruce Bassi: There are very few therapists who I feel like are appropriately trained to use a CBT approach treating psychosis. Even for somebody who’s really well qualified, very nuanced, understand the psychotic what their conceptualization is of reality. and getting into all of the details of their perspective on reality.

Kim Bullock: And so I think that’s the problem with psychiatrists. we’re already way behind the curve and even learning CBT and to use VR effectively right now in an evidence-based way, you really gotta know how to do CBT. So first you gotta learn CBT and then add VR. So like in our clinics, I have Kate Hardy, who actually disseminates CBT, for psychosis, and I think their priority right now is just that even though she’s interested in adding the VR, you first gotta disseminate the CBT for psychosis, which is still, hasn’t been fully implemented or

VR use in Psychosis

Bruce Bassi: Individuals who probably have gone most of their life without addressing that psychosis with therapy in any way. It’s usually helping with the most basic of needs, getting a quantitative assessment of how often the voices are happening

Kim Bullock: Who would think to put it in like an exposure paradigm too, the VR does it really, operationalizes that exposure component? ’cause that’s a radical idea. but pretty effective. actually, psychosis has the best, research, supporting that VR is superior to, therapy without most of the other treatments, can enhance, speed or maybe the dropout. It enhances the therapy, but you don’t get superior results. But there’s some evidence mounting that actually VR enhances, has superior results in psychosis.

Starting with VR carefully

Bruce Bassi: I think, some people are maybe just afraid of VR because I think they think. the patient’s gonna be just confused so it shouldn’t be like an absolute contraindication to treating a patient. Like shouldn’t just be like a flat out, no, like this person has psychosis. Therefore we can never. Use VR with them. Like anything, we need to be careful, start low and go slow. Like we say with medications, like nothing’s truly off the table. We’ve always used things off label if we can just make sure that the patient and the clinician is very well educated as to how it’s being used.

Kim Bullock: Well, I think it’s like Edna Foa, who would’ve thought that you should talk about your trauma that would help people you know? these people are doing these things that are just go against common sense, but then work and that. I think that. a psychosis one and avatars, you would think that would be the worst thing to do somebody who’s not in touch with reality, is put them in a non-real world.

Side Effects and Precautions

Bruce Bassi: Let’s talk about side effects. You mentioned incidents like people falling off chairs. While it might seem trivial, it can lead to trauma. What are the worst-case side effects you’ve encountered? For example, do you ever need to administer Zofran for nausea, or just give them a break from the treatment? What kinds of things are you looking out for?

Kim Bullock: It doesn’t happen very often. Even though it’s reported to happen pretty frequently, in my anecdotal experience, it’s rare if the exposure is kept under 20 minutes. The side effects could include cyber sickness, which is thought to be due to the sensory conflict between perception and vestibular systems and expectations. There seems to be a significant psychosomatic component to it, so we still don’t fully understand cyber sickness. Other side effects can include dry mouth, salivation, apathy, disorientation, autonomic nervous system disturbances in a very small percentage of cases, visual disturbance or visual fatigue, postural instability, and lucid dreaming. A lot of this evidence comes from gamers who engage in prolonged sessions, which can lead to these symptoms. There are also cases of embodied illusions, such as body swapping or body transfer experiences, leading to sensory symptoms the next day, like diminished hand sensation. This suggests we need to study these embodied illusions more. Even in rubber hand illusions, people experience a histamine effect and an inflammatory response to the disembodied hand through an illusion, indicating our perceptions and immune systems are interconnected in ways we don’t fully understand. So, we have to be very cautious.

Easing into VR treatment to reduce side effects

Bruce Bassi: That’s a really good reminder because even I know that there are real physiological changes due to a placebo effect. It’s like your mind is telling you that something is happening, and your body is actually making real changes. I imagine the same thing can happen with the rubber hand effect or reality. In one sense, we’re using virtual reality to desensitize someone to pain. Who’s to say that maybe it couldn’t go too far in the wrong direction, and like they become desensitized to other sensory experiences, tactile experiences with their hand or arm.

Kim Bullock: Right now, the way we have it set up, with just the head tracking, cyber sickness affects about 1 to 5% of people. It usually comes early in the VR treatment. For me, what increases the likelihood is textured scenes or low-quality images, ages two through twelve, comorbid migraine, self-reported motion sickness. It’s really recommended that you start with just 10 minutes for the first VR use. If people do get it, it’s kind of like seasickness. I’ve also sailed too. I think it’s my Viking gene. If anybody has seasickness, you just have them start steering the boat, and it goes away. I’ve never seen it not work. It’s the same with VR. The more autonomous control you have, the more interaction and control in the environment, the less likely you are to have cyber sickness. So having people stand up or start to do something active helps. Or just take the thing off and relax. There are cases of, luckily I haven’t had any, but I always worry that it might happen, like disembark syndrome, where people go on a cruise, they get seasick, and then they never get better. They’re seasick for the rest of their life, like a month or two. But there are cases, and I’m sure that’s going to happen, so we have to be careful. I only had it with one student that I was training. I was doing a workshop with international students, and this young girl put it on for less than a minute and she got severely sick. But that’s the only time I’ve had cyber sickness.

Consent for VR

Bruce Bassi: It kind of made me think about doing consent. We should be doing informed consent, right? I mean, these are rare, but I guess people should know.

Kim Bullock: I’ve spent two years working with the Stanford Compliance Center. I hope my Stanford department isn’t listening. This is so new. They don’t know what to do with it. They aren’t able to help me figure out what kinds of consents or anything to do, but I do think, yeah, you have to be just honest and have conversations at this point. But there isn’t any standard consent forms.

Bruce Bassi: I think it’s actually required by certain state laws now to say that the patient, we obtained consent that the patient agreed to virtual care and that they acknowledged that other people in their vicinity could potentially hear them.

Kim Bullock: Oh yeah, we have that. The telehealth has been pretty standardized. Now that everybody’s on board, that’ll happen once we get therapies using VR.

Other VR Treatable Disorders

Bruce Bassi: I’m just thinking it’s a matter of time before we have one fairly standard universal consent form for VR types of therapy with sickness and other perceptual issues. What other types of disorders are you most excited about using VR for? I know a couple of other ones that we haven’t really talked much about are eating disorders. And then the functional disorders in more detail. I know you have a more research-oriented approach to that, but do you think that this is something that more clinicians should be eventually picking up and saying, “Hey, this is a good tool. We’re short on tools in this field here. We don’t really have a whole lot of tools to go off of, why don’t we embrace this thing that could potentially help a lot of patients who are otherwise untreated.”

Kim Bullock: I am really excited about the eating disorders world. So, I’m not an eating disorder specialist, but my friends in the eating disorder clinics at Stanford have been able to accept VR and are doing studies. I think that we’re going to be able to launch them very soon. And so, because with eating disorders, there are like three components. So people are inaccurate about their body. They have body distortions, they have body dissatisfaction, even if they’re not distorted, and that’s one of the hardest symptoms. And then there’s just eating itself, like either giving into urges or not giving into urges. The easiest thing and has the most evidence and that our clinics have been able to adapt from Riva Giuseppe’s work in Italy. And they did a kind of cultural adaptation for the US has been cue desensitization, helping people with refractory eating disorder that didn’t respond to traditional CBT, and helping them desensitize to their own cues and their own foods. So that’s one low-hanging fruit, but the thing that seems to persist when people get control of their eating is body dissatisfaction. And what’s Riva Giuseppe has really done tremendous work, as well as his colleagues about, possibly this Allosteric Locke theory in which your body image is actually created from implicit biases. What you think your body looks like to other people from your culture, from your experiences, and then also from the bottom up, your interoceptive sensations and how you’re feeling. So these two come together and they create your body image. But some of that, a kind of top-down from implicit biases get stuck and it doesn’t, can’t model update. If like, you know, you were six years old and somebody told you you were fat and now you’re a regular BMI person in your thirties, you can’t get rid of that experience. And so it never updates. And so they’re experimenting with some, both, retraining these experiences and kind of like, talking about them in an avatar. But the more, compelling to me is this implicit bias reprogramming. ‘Cause you know, most of therapy you have to think about it and do it on your own. But embodied experiences can change implicit biases. So you can go into an experience. If you embody the characteristics of that person, you will start to behave like that person. It’s the Proteus effect. Jeremy Bain, his work has talked about these experiences, like if someone wears a cape in an avatar, a fully embodied experience, they see that they do more helping behaviors the week following that experience. And the same with racial biases that can change through stroop testing, people’s biases. So you can do that towards your own body. They have people who are morbidly obese trying to lose weight get into an avatar of an average weight person. And you would think that that would be super disturbing, right? And after that experience, they would get out of it and just be more dissatisfied with their body. But the opposite is true. They feel better about their body and it actually translates to better health behaviors after it. So it’s changing something in their model. This Allosteric Locke theory is what’s proposed. So to me, those kinds of things about transforming implicit biases, because beliefs are really hard to change. We can change some of them with intention, but if we can change them passively at that reptilian level, with conditioning, that would be just such a game changer. So those kind of body swapping experiences have profound effects. Because when you embody something with certain characteristics, you change your beliefs around those characteristics. They’ve done that for profiling, like having an experience of a homeless person or having an experience as a black person changes your beliefs about that group.

Mirror Therapy

Bruce Bassi: Even with someone who has pain in a particular arm, I saw your interview, was it on NBC or some other big network, where they were popping the balloons using their functional hand, and then that gave them the belief that they can use their non-functional hand.

Kim Bullock: Yes, it actually reduced the pain. But I think that’s happening through this motor M1 pathway. So mirror therapy has actually been shown to really help with pain and function. It activates something called the M1 pathway on the same side. So the illusion itself changes in the motor cortex.

Bruce Bassi: This is why we’re in psychiatry. We love geeking out about these topics because there’s so much potential there, and I think also we need to do more research because I think there’s going to be a lot of critics who say you’re going to worsen people’s self-image because it’s like, well, if they apply that thought process well, look at like Instagram. There are all these perfect bodies out there, or I mean magazines. That’s what they were saying 10, 15 years ago. But that wasn’t the person’s own body, you know, in a VR setting. And that’s, I think, the key difference there is that they’re judging what they’re seeing on a screen or in a magazine versus what they’re seeing on their own body. For what you’re talking about is that they look down and they see a different body in the VR.

Kim Bullock: Yeah, that’s an egocentric experience as opposed to an allocentric experience where you’re looking at yourself or looking at somebody else because you can be in VR and have an allocentric experience where you’re looking at two avatars, or looking at yourself like being Freud. Friedman has that one where you become Freud listening to yourself. So there are these different perspectives that may have different effects, and this is where I think psychiatrists need to get involved. I cannot find a VR company in the mental health space that has a psychiatrist. I’ve been begging to be an advisor. I can’t even get a conflict of interest. People need to know what’s going on and we need to be studying this. We need to know what happens clinically and psychologists are great, but there’s some information that psychiatrists know about the body or neurology that needs to get into the conversation. We really need to have some input into designing what’s happening in the future. And I think you’re part of that.

Psychiatrists’ Interest on the Subject

Bruce Bassi: I appreciate that. Yeah. I mean, I remember being at the APA conference in New Orleans a couple of years ago, and there was a talk about technology and psychiatry, and there were so many psychiatrists in the room. They’re like, how do I get involved? How do I talk to the people at these companies? It was this mismatch between like a hundred psychiatrists in this room wanting to get involved in some way. And then, you know, you look at the advisory board of these companies and it’s mostly people who have a business background. This is probably one of the reasons why I did this podcast. It allows me to have these conversations where otherwise I would never have been able to talk to the founder of a particular technology. And so that’s really cool. I’m sure you’re having the same experience.

Kim Bullock: Yeah. That’s exactly why I did the podcast. Yeah, I’m so glad you’re doing it. We’re in a crisis with our identity as psychiatrists going forward, and we really need to be thinking about these things and how we fit in and what we’re going to do.

Developing guidelines for VR use

Bruce Bassi: What about guidelines for VR? Do you think there’s going to be any guidelines set for what clinicians could follow? I feel like sometimes there’s a thirst for that to standardize the approach, maybe to feel like what other clinicians came up with as a safe mechanism that maybe makes me feel more comfortable going into doing this. Do you know of anything out there on that?

Kim Bullock: No, I think the APA, the psychologists are probably closer to doing that. But I think because the hardware’s changing all the time, that it makes it hard to have these guidelines. Maybe if the market settles down and we get one or two devices that stick around. But I do think some professional organizations need to be a critical mass in a professional organization to create the standards and then it needs to go into training programs. I think the critical mass isn’t there and I think also because the technology is changing so rapidly.

Bruce Bassi: And just to explore that topic a little bit more. You mentioned there are a lot of devices on the market. A couple of the top ones, the top headsets, is the experience a whole lot different, like from the patient’s perspective, that actually changes the guidelines?

Kim Bullock: We thought the Quest was going to be the game-changer. But onboarding is so difficult. So we’re all waiting for this Apple device, and Apple might be the game-changer. Everybody’s kind of holding off to really develop things until that Apple headset becomes available. I haven’t tried it yet, but I think Apple has kind of, and again, I’m not getting paid by them or anything, but they do have better privacy issues. They’ve delved into risks more and they’re a bit more cautious and they’re coming late to the game because they’re doing their research. I think once Apple’s in there, we might hopefully, we were pretty disappointed by the Quest.

Augmented Reality

Bruce Bassi: Apple really excels at augmented reality, correct? Can you, for the listener, maybe talk a little bit about how that would change the clinical approach with a patient using an augmented reality paradigm versus a completely virtual paradigm?

Kim Bullock: I think it would be easier for us clinicians because we wouldn’t have to be worried about them falling and everything. And they could use their own environment, like from the discard, the hoarding studies. I could see with augmented reality that people could practice their discarding in their real environment, then be able to do that. You know, people with phobias they’re afraid of spiders, they could be in their own home, in their environments where the fear is really maladaptive and, you know, bring the spiders on. I think it’ll just add flexibility to the simulations that we can do and make them more realistic and maybe, more applicable to their problems.

Bruce Bassi: That’s really cool. That’s really smart. I hadn’t thought of those types of applications. That makes a lot of sense.

That’s it for this episode. I’d appreciate it if you please like and share this podcast with your colleagues. It’d be especially helpful for us. And if you’d like, please leave us a rating on your favorite podcatcher. If you’re a clinician, I developed a course on how to start a private practice and for patients, I’ve also developed a course on acceptance and commitment therapy and cognitive behavioral-based therapy lessons for treating and helping anxiety. You can find all these on our website as well, as well as the show notes and resources for each episode. Thank you so much, and I’ll see you in the next episode.