#693: Pain Management & Other Medical Applications of VR

howard-roseHoward Rose is a pioneer in creating medical applications for Virtual Reality, and I had a chance to catch up with him about his company Firsthand Technology which is creating pain management applications for VR. He’s also creating medical VR applications that help with physical health, mental health, and behavioral health. Rose has a lot of deep experiential design insights into the virtual reality medium, and he’s taking an evidence-based approach to describe how the immersion, interactivity, physical and mental stimulation of VR combine into creating a “mind over molecule” approach to healing where patients become active producers of their own health care rather than passive consumers.


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[00:00:05.452] Kent Bye: The Voices of VR Podcast. Hello, my name is Kent Bye, and welcome to the Voices of VR Podcast. So I'm really excited about this interview today. It's with one of the pioneers of medical applications of virtual reality. And to me, the medical applications are one of the most exciting potentials of VR. And it, in fact, convinces me that VR as a medium is never going to go away. Going all the way back to talking with James Blaha at the Silicon Valley Virtual Reality Conference back in 2014, he told me that he was able to cure his lazy eye with VR. He was able to create a game that was able to take what was essentially his eye that worked, but it just needed to be trained through different exercises. And those exercises normally are really boring and people don't like to do them. But yet VR was able to make it fun and engaging and interactive in a way that he was actually able to do those exercises and be able to see in stereoscopic 3D for the first time. Well, that principle of neuroplasticity combined with how virtual reality is able to immerse you and engage your agency and just make it more participatory process so that health and healing is going to be less of something that you consume from these doctors and be something that you're actually actively participating in. And so this is a huge trend of allowing people to make more choices and to take more actions and to take more control over their own health. And virtual reality as a medium is going to be able to start to do that. And there's also a lot of mysteries in terms of what does it mean to mediate your consciousness in this virtual technology and what are the health benefits? And so we can start with people who are in extreme pain and see that there's some real empirical impacts of being able to use the virtual reality technologies in order to bring about some sort of real relief into their experiences. So Howard Rose is somebody who has been looking at these pain management techniques within virtual reality for decades now, and he is doing some different pilot studies and also just finding that they're getting some real empirical results, whether it's 30% better pain reduction with using virtual reality technologies, using 20% less opioids and with this opioid crisis that we have today, I think a lot of people are looking for alternatives to just, you know, treating things symptomatically with drugs and to really get to the core of the issue. And there's just a huge drop in cost for the hospitals as well. And so overall, there's getting a lot of traction for virtual reality for pain management and also these other medical applications. And so we'll be exploring all that and more on today's episode of the Voices of VR podcast. So this interview with Howard happened on Monday, April 23rd, 2018 at the Design Realities Immersed Conference in Portland, Oregon. So with that, let's go ahead and dive right in.

[00:02:48.963] Howard Rose: My name is Howard Rose. I'm the CEO of First Hand Technology. We are a software company. We've been developing applications for healthcare. One of our primary areas is pain relief. We bring virtual reality to help people with acute and chronic pain. And we're bringing applications to hospitals and clinics, helping people through procedures. So you can go into VR and it helps to reduce the stress and reduce the pain. And we find that people actually need to take less drugs. And for chronic pain, we're helping people with biofeedback and mindfulness and physical rehabilitation, and lots of different uses for VR.

[00:03:33.750] Kent Bye: So yeah, maybe you could tell me a bit about your journey into this space of using immersive virtual reality technologies for medical applications.

[00:03:41.670] Howard Rose: So I've been in VR for about 25 years. I got into it at the University of Washington. I was in a lab called the HIT Lab, which is the Human Interface Technology Lab, started by Tom Furness. And my early work in VR was in education, and I built a virtual world to teach Japanese. Kind of bleeding edge at that point. But that was really successful and looking at how VR is a way to help people perform better, help people learn better, help people be healthier. And over the years, I started firsthand with my partner Ari Hollander about 20 some years ago. So we've been through a lot of different waves of VR, but we're really excited about now we can build products and bring them to not just organizations like hospitals, but we're really focused on bringing VR to help people at home. Yeah, so my journey through VR has been really exciting. I'm a designer. That's what I like to do, is design experiences for people.

[00:04:43.869] Kent Bye: Yeah, so I know that this world where you're kind of flying around sending either bubbles or fish to sea otters reminds me very much of like the snow world type of experience where you're kind of going through and it's, you know, there's snow, it's cool. So for people who experience burns that may make them feel like they're in this cool environment, it's got nice soothing music. So maybe you could talk a bit about the experiential design elements that you're creating within this experience in order to address some of these deeper pain issues and what exactly is going on there as to how that experiential design actually can reduce pain.

[00:05:17.233] Howard Rose: Right. So, yeah, thank you for mentioning SnowWorld. So we worked on SnowWorld for about, I don't know, 14 years with Hunter Hoffman and Tom Furness and David Patterson and those folks. So our application Kool is kind of a next generation SnowWorld based on a lot of the things that we learned. And just specifically about the design, you know, we went through a lot of iterations. We build and test and do a lot of different things. And, you know, initially what we did was, you know, the computing is so much better and the headsets are so much better that we thought, OK, we're going to make things more realistic. So we built things that were not photorealistic, but they were more closer to reality. And what we found was that Reality was kind of heavy. So we had these snowy scenes and it's snowing and there's a way that that's really beautiful, but it's kind of like when you go out on a real snowy day and everything feels really still and sort of dead. And, you know, like nothing's moving. That in VR is not really successful. And so there's a way that reality is also kind of boring. It's kind of limiting. So we have otters in our environment, and when the otters had to be really realistic, anatomically realistic, you can imagine being next to a 40-foot realistic otter. Otters are basically weasels. And like a 40-foot weasel, we called it the 40-foot weasel problem. And so reality kind of locks you into certain challenges, and in a way you kind of lose what's really exciting and interesting about VR. So we stepwise backed off of that. and we've changed the colors, we've changed sort of the dynamics, and we found this sweet spot where it's, you know, one of our goals, because we're dealing with pain, is that people, especially people who have never tried VR, need to come in, feel comfortable, get active, and start using it immediately. Like, immediately. There's no training. And so we needed to find a space that they feel comfortable with, but also that is interesting and fun and engaging. And so that was sort of our design challenge. And we think, cool, judging from the outcomes, we see that it's really successful.

[00:07:42.133] Kent Bye: Yeah, I remember the last time I had tried this back in Seattle, 2015, you were just maybe shooting snowballs at these otters, and you were hitting them, and somebody, I think, had mentioned, well, I want to be able to help them in some ways, and I think the fact that you're able to shoot fish to them now and feed them rather than throw a snowball in their face, I think people can get behind a little bit more if they may be against shooting things, but also when you hit them, they have this little magical texture. have a glowing orb that goes around them, they transform, they maybe do a little dance, and I found that it was enough variety in the different types of things that happen when you actually hit that it makes it interesting to kind of, like, fill you with more curiosity or awe and wonder to try to continue on, probably longer than I would have done ordinarily. I sort of get the mechanic very quickly, but there was something about both exploring the different landscapes, but also just seeing what kind of either animations or surprising things that these otters would do if I were able to actually hit them.

[00:08:38.407] Howard Rose: Yeah, well, so we did add the trout cannon, which is, you know, so we have bubbles and these orbs that you can throw and the trout, you know. It's really interesting that people feel, even though the animal is obviously virtual, they feel an affinity for the animal. And, you know, we're pro, we like to take care of animals and we don't want violence and we try to make our experiences engaging but not, you know, you're killing stuff. But, you know, that starts with people really do feel, they feel that, there's a visceral feeling if I hit something and I hurt it, even though it's a, I know it's just a virtual otter. I feel that, and I think that's an evidence of how engaging VR can be, and we don't even think about it, we don't even, like, you just feel it. And so, yeah, the adding the fish has been a, you know, people like it, people get into virtual environments, and, you know, most people now, I think in the evolution of where VR is, when we started, you know, two years ago or whatever, Nobody had tried it. I mean, a very small number of people. Now, a couple years later, you know, most people have at least thought about VR. It's stopped being something from science fiction, and it's something that, oh, you know, I tried it once or twice. But, you know, still, for most people, they don't really know what a good VR experience is. And so our fish and the bubbles, that's all part of trying to make this an accessible, fun experience. You know, and I can share some recent data so that we just finished a pilot implementation with Providence Cancer Center. So we're here in Portland. and we're working with Providence. And in that case, we were working with pancreatic cancer patients, and these are their most challenging patients in terms of, you know, they have a lot of pain, they have a lot of chronic pain, they have acute pain, and the outcome was really great. So with these patients, they have a large incision, kind of surgical procedure, and they're in the hospital for a week. And that experience, you know, they're taking a lot of drugs, they're taking a lot of opioids, they're lying there, they're depressed, and part of the therapy is they want these patients to get active. And if you're taking a lot of opioids, you're not feeling very well, and it's an obstacle to becoming active. So, yeah, we worked with them and using VR with these patients who, you know, they're generally an older set, you know, a lot of 60, 70-year-olds, and the outcome was great compared to, like, the standard of care, which is drugs. We had 30% better pain reduction, so they feel less pain, 20% less opioids, so they're taking less drugs, and a big drop in cost for the hospital, cost per patient. So that's a really fantastic outcome, and I think it's indicative of what VR is going to be doing in terms of, you know, in the long run, I think we can amplify that effect and make it even better, but also, you know, bring it to more hospitals so more people can enjoy the benefits.

[00:11:51.603] Kent Bye: What are the other type of demographics in terms of where you find these types of VR applications that you're specifically building, like, really applying? Like, what type of medical conditions and things are you really addressing here?

[00:12:04.475] Howard Rose: Right. Well, you know, for us, we've worked in many areas of healthcare. So, I kind of divide that up into physical health, you know, pain, fitness, all sorts of those kinds of things. mental health, anxiety, depression. People are using our applications for kids who have inhibition control or emotional regulation issues, ADHD, lots of those kinds of conditions. And then the third area is behavioral health, helping people adopt better health care habits. And I think that, you know, we're going to see VR working in all of those areas and also, interestingly, kind of blurring the lines between them. Because if you think about opioids as kind of an example, everybody knows about the opioid crisis, right? We've gotten ourselves into a situation where we take a pill, we numb ourselves to the temporary pain, but it doesn't actually cure anything. VR is really interesting, so our application Glow, incorporates a biosensor, we're using biofeedback, we use the immersive context of VR to help people relax and access their internal capacity to relax and be more resilient on their own. I think of that as sort of mind over molecule, right? Instead of introducing a molecule into your system, we're using your innate capabilities and VR is a tool to access that. So what I was getting to was that kind of blurs the line between, you know, we don't think of pain just as something as happening in your nerves and just a nerve signal. Your brain and how you react and how you interpret those signals and the kind of mental strategies, mindfulness that you employ, have a big effect on changing pain into suffering. And what we're really doing is we're addressing suffering. And we can help you through either a procedure where that's happening or help you long-term with chronic pain and address not just the pain but also the anxiety, the depression, the feeling of helplessness and all of that. So it kind of blurs the line between a lot of different sort of classical distinctions in healthcare.

[00:14:15.027] Kent Bye: Yeah, and you had mentioned that there's the physical health, the mental health, as well as the behavioral actions that people are taking. And I'd say that another one would probably be emotional health and PTSD and trauma. And I know that Skip Rozo has some very specific protocols where he has people come in and sort of recreate the context in which they're going in. there's an emotional telling of the story where they're able to tell the story and be able to really attune to the emotions that they're getting present with. And that seems to me that you almost would need to have a counselor there to receive that story or to help mediate that or to control the exposure therapy of all that. So with your company, I'm just curious if that's sort of a hard line that you see that the PTSD and those other emotional traumas that people go through, if that's something that is a little bit more complicated to try to automate within a self-contained experience.

[00:15:04.905] Howard Rose: Yeah, well, so Skip Rizzo, you know, Skip's down at USC and he's doing awesome work. We've also worked kind of parallel and sort of collaborated on, so we've done PTSD applications, exposure therapy, other kinds of areas of mental health. So the work with PTSD that we did was also with the military. And you start out with people in the military have a reluctance to even admit that they have PTSD and they don't want to confront it. And then if they do confront it, they want to confront it with their peers or a therapist, but a therapist that really understands them. Like there's a very strong culture of soldiers and the wounded warrior and that. And the way the VR fits into that is that, you know, I think of it as VR turns talk therapy into action therapy. That instead of engaging with the reluctance to even go there, that they get into VR and they just do it. that it sort of bypasses our biases and our reluctance and our inhibitions and we're just in an environment. Humans are environmental animals. We evolved responding to our environment. So if you put someone into a different environment, they will respond differently. And so rather than talk therapy where we sit around and go, You know, I have this problem and cognitive behavioral therapy is great, but it takes a lot of time and it takes a lot of effort and you have to really want to engage in it. VR bypasses that and it can be a catalyst to enable people to open up to their therapist. Like, you know, what you find with the soldiers that were using our system or Skips found the same thing is that once they engage in it, it sort of opens the floodgates and they're like, this is what happened to me. And if they can point to the stressors, the experience that induced the central core post-traumatic stress, then they can confront it. There's an element of desensitization where they can get used to it and they really understand the triggers that are around it. And then what you see is a tremendous drop in the kind of the problems, the overreaction, the stress, the sleeplessness, all of that. So the symptoms significantly are reduced.

[00:17:27.955] Kent Bye: Yeah, and it seems like that with the GLOW, starting to integrate biometric data into this, that you're really tuning into someone's body, what's happening to their body. And that when you say that you're doing mind over molecule, you're using the body's innate capacities to heal itself. But the problem is that that sometimes requires a lot of patience to go through the either meditative contemplative practices, which don't have immediate feedback, which you may have to invest a lot of time and energy before you actually see any feedback. So it seems like with the VR you're able to do like instantaneous feedback so that you can sort of see the impact of what's happening with your body but somehow gamify that so that there's a game progression curve but that game progression curve is actually cultivating this deeper body wisdom so that you're able to actually handle some of the stress above and beyond what had used to be addressed by taking a drug. So that process of gamification though seems like you're taking these sort of ancient wisdom traditions and contemplative practices and trying to find step-by-step how can you measure that or start to use the VR technology to measure it to be able to have a game progression curve to allow people to make it fun or to see the immediate impact of their agency.

[00:18:37.645] Howard Rose: Right, I do think it is a combination of sort of an East-West perception of the self and perception of health. I think that the term gamify is really an interesting one and even just the term game. So just around that, I mean we try to create spaces, we try to create places and use VR is something that, so, we're not going to keep people in VR 24-7, right? We want to give them real value while they're in it and then give them some benefits so when they take off the helmet, they both feel better and they are better people. They're better at doing whatever they want to do. So, the real test is what happens when they take the helmet off. But when you think about what happens inside of the helmet and sort of that east-west balance, and you talked about sort of the role of the therapist, you know, and I'm a crummy meditator, right? I'm terrible at it. I sit there, I'm thinking about my job, I'm thinking about all the things, that email that I got to write, and my phone, and oh my god. and I just, I can't quiet my mind. VR is a way to help people access that, and it's not really a game in the sense, we try to take the best of what games do. Games are about engagement, and they're about stickiness, and they're about rewards and benefits, and it's an intrinsic motivation. So people don't do stuff for badges, right? I mean, I think that's kind of, That's kind of limited, right? Oh, we'll give you a gold star. And yeah, that can work. I think some people do. Yeah, people do that. But when you talk about health, when you talk about my health, I do it because it makes me feel better. I don't do it because somebody gave me a little otter-shaped badge, right? I mean, an otter-shaped badge can keep me interested. I can gather the gold or whatever and increase my health or my strength or whatever in your game metaphor. But over the long term, it's got to deliver some other benefit to me, right? So that's a great example of, you know, a badge is a game mechanic and it has some sort of psychological and other kind of game significance to it. And you can incorporate that, but that's not the reason that people do it. The reason that people do these applications is because they do it, they feel better, and they immediately know they feel better. They don't need a longitudinal study. They come out of it, they're like, wow, I feel better. And so we can employ those game aspects to keep them engaged, to keep that stickiness to the best of it. But as I was saying, you know, that point about games is we think of these as experiences. That's the word that we're using right now. The word game kind of trivializes things in one mindset. So we don't want to be in a situation where you don't want the spouse going, oh, honey, just get over it, play the game. It's all in your head. And what I believe is that the problem, the pain is not in your head, but the solution can be. And if we can help people access that and address it, it can be a tool. But that doesn't imply that your pain is trivial or psychosomatic or whatever. And so that's the kind of weird, interesting dynamic around the word game. So we don't really think of this as, we're trying to find, we're inventing a new genre, really, of therapeutic environments that have the capabilities built into them, the affordances are built in, and that people naturally get the benefit without having to read a manual. But there is a role for the therapist. I don't really believe in therapy in a box. And I certainly wouldn't recommend that for people who have extreme phobias or PTSD. You need to work with somebody who can help you through the actual emotional process. We have a psychiatrist who's using our applications for, you know, emotion control. and all of that, and helping kids to, you know, if you have a kid who has bad emotion control or inhibition control or ADHD, they have a real problem finding a place, you know, a calm, quiet place. You know, she's got a patient who locks himself in the bathroom. and a big family and then they have to find a way to get him to calm down and relax. So they're like, okay, remember when you were in Glow and close your eyes and think about the fireflies and go to that place again. That's a way that we can help people out in the real world and use VR as kind of a positive reinforcer and a trigger and a way to learn.

[00:23:15.769] Kent Bye: Yeah that makes sense and the way I think about it is that in games you have mental and social presence as well as active presence so you're making choices and taking action and it's about this kind of young archetypal journey of the hero's journey of you going outward into expressing your agency but yet I think there's sort of a competing yin archetypal journey that it sounds like that these types of medical applications are trying to generate which is that you are getting present into your body trying to cultivate to your breath and try to really use your own innate healing capacities to maintain that sense of embodied presence as well as emotional presence and to be able to connect to the environment and in fact support the environment and feed the environment and nurture the environment with the fish and other things so that you're actually Helping cultivate these animals, but you're also cultivating that sense of awareness and presence in yourself and that there isn't a lot of good Metaphors that we have in our culture for what this yen archetypal journey is I think Japanese culture may have some things with different narrative structures that they have that are trying to tell a story that shows the interconnectivity of everything but yet here in the in the West I think that we have video games we also have film that try to also take you on an emotional journey but this is bringing the body into that situation for the first time where you're able to create that both embodied and environmental presence.

[00:24:30.895] Howard Rose: I think that, you know, what that kind of reminds me of is, you know, people use the word distraction. And, you know, pain distraction is certainly a concept that, you know, if you distract somebody, look over there or just, you know, do this and you won't feel the pain. And we think of it as activation or engaging and activating the patient. and it's not just go into VR and you won't be doing this. What's really cool about VR is that it is a hyper-focused experience. You know, like, when you put on a headset, either our environments or somebody else's, you are so there, and you are not thinking about your phone. And our natural state of being in our modern culture is a state of distraction, and we're multitasking, and we're doing so many things, which is the genesis of stress. And stress is the genesis of a lot of disease. And if you look at where illness is happening in our society, so much more of it is happening from lifestyle choices and lifestyle habits and stress and overeating and not exercising. That's the main cause of our problem. Getting attacked by a wild animal, we're not suffering from that much anymore. So our problems are sort of, if you want to call it self-induced, where if we had better habits, if we were less stressed out, if we were more focused and able to access those parts of ourselves, we would be healthier. And so there's a real benefit in trying to change the way healthcare happens. I think of it as, you know, we're trying to take people from being health consumers to health producers. And instead of just consuming health services, and the hospitals are providing health services, that's backed our way into an economically untenable situation. We spend $3 trillion, 18% of our GDP on health care. We spend more than any other developed nation, and we get the worst outcomes. And a lot of that is because the way we use healthcare is not either efficient or it's not really addressing the problem. Like once you're a diabetic, you're in a bad place. But if we can get people sooner and change their habits, change their exercise, what they eat, the way they feel, their stress, you know, you can address and really reduce the reliance on our medical system. So I think there is a, you talked about the personal journey. Like, cool is, you know, cool, our son of SnowWorld, is an external journey. You're going through an environment, you're interacting with things out there. Glow is a very internal experience. And what's interesting is that people are not used to having that kind of experience. Like, they come and they go, what am I supposed to do? And I tell them, well, this is really about not doing. This is really about finding that space in you, using the environment in a way that benefits you and helps you access that. You know, we have these lanterns, we have these animal lanterns that show up and it's not a lantern filling task, right? It's not about how many lanterns and badges do I get. It's about the lanterns are also there. There's a metaphor. I can gather a whole bunch of fireflies. I've got this light. I play with it in my hands. My hands actually start to feel warm physically because of this light and all of that. I take a big exhale and I just let the fireflies go into the lantern and when the lanterns are full they glow and they fly away but the point isn't how many lanterns did I fill it's me being in a physical and mental space of being able to to kind of just relax and chill and not do and we're so bad at that.

[00:28:32.278] Kent Bye: Well, there's something that's, I guess, a bit mysterious as to the mechanisms of how this works. I mean, in some ways, you said that somebody tried this last night, and she had hand pain, and then she told you afterwards, anecdotally, that her hands no longer were in pain. And, you know, on one level, from a Western mind, you may say, well, maybe this was psychosomatic. She was just sort of, it was never really there. But yet, the real experience of that pain is there and they can have these experiences where they're perhaps fully present with their breath connected to their body expressing their agency kind of making choices and you know really kind of engaging into the story or their emotions but there there's something about their cultivation of that presence and their interaction with the experience that something happens what's happening right

[00:29:13.720] Howard Rose: Yeah, that's the great question. So here's how I think of VR. So VR has kind of four superpowers. Immersion, interaction, it's physical, it's psychophysical, and then there's this mental level of what you're actually doing. And if you kind of take that apart, immersion is where it all starts. So I am mentally and pretty much physically taken out of the treatment room and not thinking about the nurse who's scrubbing off my, you know, causing all that pain. And I'm mentally taken somewhere else. So immersion is kind of where it starts. It's not where it ends. It's where it starts. Interaction is a really big component. You know, people ask me, well, what about a 360 video? And I'm like, okay, that can be beneficial, but you can't play a movie better, you can't play a movie harder, you can't make any choice. And because of that, I mean, you sit in a theater and watch a giant screen, nobody reaches up and tries to change what's happening on the screen. You're in a passive kind of recipient mode. And when you put people in interactive environments, they can choose in cool, they can choose to be very active and engage with the otters, or they can just sit back and watch the snow. It doesn't matter, but mentally they know they can make choices. Ow, that really hurts, I want to do this more. You can't do this more in a video, you're just watching. So the interactive component we've also found from the research is also a big contributor to the effect. When you do this and it's not interactive, it's not as good. The psychophysical aspect of it is another dimension that we can kind of work with. So in Cool, you go over, for example, a waterfall. I have been over that waterfall hundreds of times. Every time I go over, I still get that physical sensation of motion. And that's something that we need to, as designers, be really cognizant of. We don't want them to be motion sick. and thankfully people don't get motion sick and cool but you know we've been able to design it in ways that that are much more accommodating and friendly but yeah so the psychophysical aspect is another thing that draws your attention and your body in and then the last one is mental health you can think of it as everything from puzzles to engagement to motivation to anticipation. And the way that these play out in terms of modalities of therapy, you know, immersion, the basis is down regulation, emotion regulation. That's kind of the mechanism. It enables you to not be freaked out and to be more calm. The interaction is, it engages sort of this creative self. So it's kind of what I was talking about, about how you're in an active, you know, people say, you know, lean forward or lean back, you know, you're engaged rather than a recipient. And so many of our medical kinds of experiences, like you think of going to the dentist, that's the epitome of being helpless, right? You're just sitting there and it's done to you. So if you can make some choices in that context, it empowers people and they feel less helpless. So the third level, the psychophysical thing, is like, I think one of the big mechanisms is the relationship to your body map. And if you look at brain scans of what happens when people are in pain and stress, and they're in VR versus not VR, you see that the areas of your brain that correlate to your body map, so that's the mental sense of where my limbs are and my body in space, when you're in pain, that becomes really activated. Oh my God, my shoulder, my shoulder, my shoulder, oh, it hurts, it hurts, it hurts. That becomes a lot quieter. And so we become interestingly and productively detached from our physical self. Of course we know where our limbs are, but we're just not as uptight about it. And the mental aspect you know those same brain scans show that brain activity moves from these parts that your brain is engaged in in pain and thinking about your body and fight-or-flight response that that gets a lot quieter and the brain activity moves to parts of your brain that are engaged in problem-solving and resilience and cognition and things that are associated with much more productive kinds of responses. Yeah, so we build environments, that's sort of the framework that we use, and we build environments to try to maximize the outcomes based on that.

[00:33:36.483] Kent Bye: That's awesome. And for you, what are some of the biggest open questions that are driving your work forward?

[00:33:42.293] Howard Rose: Wow, there are so many questions. I mean, you know, we were engaged in the research side of things for a very long time, and there's still a lot of great research to be done, both in terms of everything from human factors to... I think the biggest area that people need to look at is, you might call it content. It's like, how people respond and, you know, there's some great work Jeremy Bailenson's doing with, you know, avatars and the sense of self. There's so many different avenues of just looking at content and how we act and behave in virtual worlds that's very replicable and very testable that that's kind of an interesting place. Some of the big opening questions I think are, you know, we're focused on healthcare. And my main focus as CEO firsthand has been much more on the translational side about how you change organizations like healthcare organizations. They're very reluctant. On one hand, you've got healthcare, which is the epitome of tradition, of do no harm. You know, it's a very slow moving animal. And then on the other side, you've got the drive and the vibrance of technology and VR and the Silicon Valley kind of disruption. We love disruption. We just show us a problem and we'll disrupt it. And healthcare doesn't like to be disrupted. And so I think the challenge that we face is we've been very methodical about this. We try to have a lot of integrity and do very science-based kind of thing, evidence-based. It's not just my assertion. And then what we're seeing is on the health side, we've got all these drivers. We've got a national problem with opioids that everybody is going, we need to solve this. So the ground conditions are really prime, but I think the challenge that we face is kind of blending those two worlds, that we're ready to move really much farther and much faster, and we can address some really challenging, stubborn problems. different kinds of conditions and different populations and, you know, reducing drugs and creating alternatives for people. And the biggest challenge is to, within our very fractured landscape of insurance and delivery and doctors and hospitals and clinics and therapists, and America is just like a big fractured mess, really, in terms of healthcare. And so it's a great place to innovate. America is a fantastic, you know, very innovative culture. It's a great place to come up with new ideas and to develop them. And the challenge that we face is really the social change around medicine and the way that people perceive of health care. Like you, for example, how do you perceive of health care when, you know, nobody wants to go to the doctor. God forbid, you know, I'd have to be dying to want to go to the hospital, right? But I want to be healthy by myself. And that's probably everybody who's listening to this, right? We all want to be healthy on our own. So I don't think of my health in terms of the hospital. And every time I interact with it, I have to pay a lot of money, right? So digital health, I think the promise that that brings is helping people at home and changing people's perception of what health is and becoming more active players instead of like, I'm just going to go about my life and have my crummy habits and be really stressed out and overwork and not exercise. And then when I get really sick, I'll go to the hospital and they'll fix me. They'll give me a pill and I'll come home. So there's social change in the institution level. There's really social and mental kind of changing our own personal attitudes about health. And that's the way I see it playing out.

[00:37:28.430] Kent Bye: Great. And finally, what do you see as kind of the ultimate potential of virtual reality and what it might be able to enable?

[00:37:37.525] Howard Rose: Well, so I at the heart of it, I look at VR as a way to increase human performance. So my background in graduate school, I studied education, educational technology. And that's how I got into the whole thing at the Hit Lab. And what you find is that what's really cool about VR is that it helps the people who need help the most. And that's true kind of across the board. So if you think about education, The people who are having success at sort of the traditional approach, which is, you know, textbooks and lecture or whatever it is, VR is an enhancement. You know, VR can help them, but it's not going to be the make-or-break-it thing. But the kids who are not having success at the traditional way of doing it, for whatever reason, they get the biggest benefit out of another approach. And you see that sort of in healthcare, too. If you think about it, you know, people who are feeling vulnerable and stressed out and having problems, those are the people we need to help. If I'm healthy, changing my habits, getting me to pay attention and change my habits, like, I'm a healthy guy, I don't need to have to worry about that. I can, you know, just keep eating this and I'll do whatever I'm doing. But the people who are really vulnerable and the people who need the most help are the ones who are going to get the most help from VR. And that's a really exciting thing. So I think the potential is that we use that as a gateway. For us, we build pain relief applications, but our vision of VR is much bigger. And we really see it in terms of human potential at every dimension. And you can frame it as health, you can frame it as education, just making people into, helping people be better people with VR. That's our goal. And I think that's the potential of the technology.

[00:39:26.082] Kent Bye: That's great. Is there anything else that's left unsaid that you'd like to say?

[00:39:29.435] Howard Rose: No, but I want to say thank you, and I hope people out there will think more deeply about VR, that it's not just entertainment. My company is called First Hand Technology. We have a lot of data at firsthand.com, and we invite people to come and learn about the technology. My name's Howard, and you can learn about both the research behind it, and some of the uses, and some of the applications that we're bringing to hospitals today.

[00:40:00.142] Kent Bye: And just a quick add-on here because you mentioned data I just want to bring in privacy here because I think that biometric data is an important thing from your perspective of kind of walking in both worlds of the you know HIPAA regulations and health care that I think biometric data to me is the thing that almost like freaks me out the most about VR especially when if more and more of the sensors are built into the technology if companies are recording that information and we're getting over our biometric information to big large companies and Do you have a specific stance on privacy or the importance of privacy when it comes to biometric data?

[00:40:32.615] Howard Rose: Yeah, I mean I start from the position that people should own their own data and that Data is such an interesting thing I mean, you know, especially right now with all of the data leaking and and you know What are they finding out about people? I mean, I personally am appalled by what happens with people's data and and financial data and health data and political data. I think that that creates a climate of mistrust and we need to find a way to kind of break through that. So here's the challenge. A lot of the potential of VR is really the ability to have it react to you. And that's what we're doing with biosensors. We have the virtual world reacts to you and the more that we can know about you, or the more that the virtual world knows about you, I don't need to know about you, but the more the virtual world knows about you and can react to you, the better the outcome. And so that creates a desire to be able to store that information about you somewhere. The more control that I can give you over that data, the happier that I am, both from my own sort of idealism and also from a business standpoint. I don't want to be responsible for your data. And so what we do today, so firsthand does not gather data about you, but the application has the potential. So if you're in a hospital, the doctor can choose to record that information about the session. It's anonymous. It's saved to a little file on the computer and it never comes to firsthand. We do that because the doctors want to know how it's being used and they want to I mean it's part of your care in that environment and I think that that's totally legitimate and we put that in the hands of the physician and that's physician-patient relationship. I think in the long term this is a bigger social question that I also don't want to you know give up my data to I want to be control who has the data. I would love to have control of more of my data and be less subject to what happens when there's a breach at whatever, some credit agency. They steal my identity. But it's a really interesting question for all of health because in a way it's that conflict between technology disruption and opportunity And you can say it's a more like sort of conservative value of really preserving what we have and preserving my integrity, my individual rights. And, you know, my personal stance is that I want to see my rights maintained. I don't want to give my rights over to the digital cloud. but I do want to be able to, in the long run, derive the benefits. So, in general, I think the best solutions are where you can control your data, it's very transparent, it's not being collected behind your back, and it's not being sold or stolen by other people. And FirstHand is really committed to doing that. That's how we will implement it.

[00:43:46.996] Kent Bye: Yeah, I just wanted to clarify that because when you say you have a lot of data it's sort of like De-identified data in the context of medical research and science but yet I think that it's a challenge of like every anytime we give data over to a company the third-party doctrine says that we no longer have any reasonable expectation for that data to remain private so as a as a culture, as we allow these huge companies to record and store biometric data, I see it as like this new frontier of having access to our unconscious patterns and that like the more they have access to that, the line between predicting and controlling behavior starts to blur and create these psychographic profiles where it's like this ephemeral emotional and physical data that I should be able to be in control of and so I can imagine a situation where I can do these applications and store it locally so if I want to look at things over time and do this quantified self thing that I have the ability to do that, but as soon as I hand it over to the cloud or to some company to maintain it, then there's all sorts of deeper privacy as well as health issues that start to get really messy and blurred.

[00:44:46.291] Howard Rose: Yeah, and I think that hopefully we as a society will be developing more systems that are not just transparent but we can develop more technologies that give you the control because you have really no way to trace what happens to your data is the essence of the problem and it's the anonymity of the internet and the ability for people to both steal it and you know what happens behind the scene and even just the cookies that are going onto your computer they're probably the bigger compromise of your own integrity and your own privacy than anything else. And that data is shared between partners and, you know, all of that is happening. You know, I hope that rather than sort of take a chicken little sky is falling kind of fearful reaction, I think that people need to get engaged People don't understand. Like, the general population does not really think about and doesn't have the experience or the kind of knowledge about how data is being used even today. And people will just put their data into websites. They'll do things that, you know, it might say in the fine print, we're not reading the fine print. I don't read all the fine print. But people need to start developing the habits of being mature, responsible, digital players. And right now, so much of the power, because of lack of information or ignorance or, you know, I'm just not interested and motivated to really do it, you know, the corporations are taking advantage of that. And I think that healthcare is one place where HIPAA is a very clear delineated line. And you have to have a HIPAA server if you're going to have that kind of data. And I am subject to, if I do research, I have to pass a human subjects test. You can't just ask any question. You have to have a reason to ask that question. And maybe there's some good lessons in there for the rest of the world where we can you know where this data is stored, that data is stored securely. Somebody had to look at the questions that you're asking, and you didn't get to just ask everything. I mean, there's some slippery slope stuff there. But I do think that HIPAA could be a good guide for maybe how we treat all of our data in this society.

[00:47:16.107] Kent Bye: Awesome. Well, Howard, I just wanted to thank you for joining me today on the podcast. This has been a great discussion. I've learned a lot.

[00:47:21.770] Howard Rose: Thank you. Yeah, well, thank you very much. It's a pleasure.

[00:47:25.253] Kent Bye: So that was Howard Rose and he's the CEO of First Hand Technology. So I have a number of different takeaways about this interview is that first of all, I was just really impressed with Howard's depth of knowledge when it comes to experiential design principles, but also the scientific backing up of some of these concepts that, you know, I've been talking a lot about these different dimensions of presence and it, it seems to have a pretty consistent mapping over to how Howard seems to think about experiential design as well. And so he said that the four major things that you really wanted to have is immersion, interaction, having a psychophysical effects, as well as the mental aspects of experiential design. And so. with the immersion that's a lot of the emotional presence and the basis for why virtual reality is so effective is that it's immersing you and that is allowing you to have a down regulation of over stimulus of an environment but take you into a completely new context but then you're able to have better emotional regulation within that new context. And then there's the interaction and the agency of you being able to actually participate and to be able to engage your creative self within this environment. And that has been found to be one of the big contributors to why some of these different treatments are so effective is that it's creating this context for you to actually participate and to get into these different flow states that are stimulating different aspects of your brain as well. Then there's the psychophysical mind-body relationship where it's your body map which is your proprioception of knowing where your limbs are and if you're in pain then you have a hyper focus on that and that body map is being activated and then in some ways the virtual reality is doing this productive detachment and disconnection to our physical body. I would just point out that I think sometimes you can actually have a deeper connection to your embodied presence within VR, but this is more of a medical application to be able to functionally sever some of those connections with that body map. So you can actually use other aspects of your brain, which is the final part of the mental level, the mental presence, which is rather than just focusing on the pain and the fight or flight response, it's allowing you to do problem solving, to have more resilience and cognition, and to actually make choices and take action in a way that is going to really take the focus off on your pain. And so at the end of it, people just have a 30% better pain reduction, they feel less pain, they're able to use 20% less drugs and opioids, and there's a huge drop in the cost for the hospital. And so to me, I think there's just so many different compelling applications for virtual reality, but the medical one I think is the one that is one of the most exciting, but it's also the one where There's just so many institutional structures around the medical field that it's really difficult to just go in there and disrupt. And so it sounds like firsthand technology is using a lot of empirical and evidence-based results in order to show that this is an effective method. And then it's a process of just saying, Hey, this is a cheaper and it's better for everybody. Let's, you know, start to deploy these different technologies into hospitals. A couple other things that were sticking out to me was just the focus on games and how there may be a cultural association for gaming, especially for people who may be a little bit older and didn't grow up with video games, and that there's a risk of calling something a game that is going to minimize the pain that someone's experiencing. I think Howard was really careful to say that, you know, what you're experiencing is real. The problem of pain isn't in your head, but the solution can be. And so there's something about being able to mediate your consciousness through VR that is then able to show all these different medical impacts. And so there's other different aspects of using virtual reality to address pain, whether it's your physical health and pain and fitness, their physical body, your mental health. So whether that's anxiety, depression, inhibition control, emotional regulation, and people with ADHD, behavioral health, so people to actually adopt better health care habits. And then finally, just dealing with PTSD and trauma and telling the emotional aspects of your story in order to actually heal from a lot of these traumas. Another quote that Howard said is that VR is turning talk therapy into action therapy and it's allowing people to actually be immersed within some of these environments and to be able to Participate and to cultivate these various different flow states and I think once you get into that flow state you get all these different Aspects of your whole body working together and from that I think we're seeing a lot of different Medical benefits from all these different areas from the physical health mental health behavior health as well as dealing with PTSD and trauma So I think there's this other big trend, which is that we are very much consumers of our healthcare and virtual reality technologies are allowing us to take more control over our health and to be able to participate in our health rather than have it something that's delivered to us as a service. Howard said that we spend $3 trillion and about 18% of GDP on healthcare here in America, and that we spend the most, but yet we get some of the worst outcomes. And so it's just not efficient. It's not really addressing the core of the problems. And. there's a very symptomatic approach rather than really getting to the core of the various issues. And finally, there seemed to be a real Dallas perspective, which is trying to cultivate this process of not doing so glow is really about not doing is what Howard said. And so it really is about focusing you on your internal experience rather than you going out and doing something explicit. And so It's this process that I think that as you start to cultivate that mindful awareness, you start to have these insights of the power of consciousness to be able to do what Howard says, mind over molecule. So rather than relying upon a drug, what can you do within the own capacities of your own body's innate capacity to heal itself? What can you do to be able to get into a state where you're reducing a lot of the stress and a lot of the distraction? Because Howard is saying that a lot of that distraction is a lot of those things that are causing the stress, and then the stress is then leading into all these other different areas. And so if we're able to get to the core of the problem, which is getting away from the distraction to be able to cultivate this ability to have this mindful awareness of your body and your emotions, then from there, we can start to have the seeds of what it takes to be able to find the resilience to be more on your own and to go from being a health consumer to being a health producer. So, that's all that I have for today, and I just wanted to thank you for listening to the Voices of VR podcast. And if you enjoy the podcast, then please do spread the word, tell your friends, leave a review on iTunes, and consider becoming a member of the Patreon. This is a listener-supported podcast, and so I do rely upon your donations in order to continue to bring you this coverage. So, you can donate today at patreon.com slash voicesofvr. Thanks for listening.

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