On October 6, 2020, Dr. Brennan Spiegel released his book titled “VRx: How Virtual Therapeutics Will Revolutionize Medicine,” which is an amazing survey of different applications of what could be called virtual medicine, experiential medicine, digiceuticals, or cyberdelics. The FDA is calling it Medical XR (MXR), and they’re recognizing it as an entirely new field of medicine that needs special regulatory considerations.
Not only is Spiegel’s book a comprehensive survey on what’s happening with virtual therapeutics, but also explores this fascinating intersection between neuroscience, psychology, clinical medicine, technology, the Mind/Body connection, embodied cognition, & different branches of philosophy but specifically the philosophy of mind and the mysterious nature of consciousness itself. Spiegel is able to deftly explore all of these different dimensions through George Engle’s bio-psycholsocial model of medicine created in 1977 or from how the World Health Organization in 1947 recognized that there’s a physical, emotional, and social dimension to health. VR is helping Western Medicine transcend the biomedical lens of health and healing, and start to leverage the body’s innate healing capacities that can be unlocked though digitally-mediated experiences.
Spiegal has also been deploying VR to over 3000 patients at Cedars-Sinai Hospital in Los Angeles, California as a part of patient care and research projects. He was a co-author of a paper titled “Recommendations for Methodology of Virtual Reality Clinical Trials in Health Care by an International Working Group: Iterative Study” that aims to develop a methodological framework to “guide the design, implementation, analysis, interpretation, and communication of trials that develop and test VR treatments.”
I had a chance to talk with Spiegel about this whole new field of medicine, and what it can teach us about the underlying mechanisms of perception, health & healing, and the mysterious nature of consciousness itself.
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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 on Tuesday, October 6th, 2020, Brendan Spiegel released a book called VRX, How Virtual Therapeutics Will Revolutionize Medicine. And this is a really fascinating book because it's going into this whole new field of medicine that is adding virtual reality into different contexts under which they're getting different therapeutic effects. And so it's not only looking at the medical context here, but it's also looking like, how does this work? It's doing all these different things with modulating our perception and having these experiential contexts that then that has real therapeutic impact, whether it's on PTSD, anorexia, or pain management. I mean, it's sort of like, what is the mystery of consciousness? It's a lot of these deeper philosophical questions that is really getting at the heart of our perception and this intersection between neuroscience, psychology, clinical medicine, technology, the mind-body connection, embodied cognition, different branches of philosophy, and specifically the philosophy of mind and the nature of consciousness itself. And so Brandon Spiegel, he's a research physician, but he's also at Cedars-Sinai Hospital deploying virtual reality out and seeing how it actually impacts different contexts, specifically in pain management at their hospital. But he's also got this background in philosophy and trying to tie all these different things together. And the FDA actually has a whole new branch they call MXR, so medical XR. So it's a new branch that's going to take the affordances of virtual reality and applying it to specific contexts to have real therapeutic impact. And so there's a whole new field of medicine, and Brandon Spiegel is suggesting that we need these virtualists, people who are in charge of understanding the VR technology, understanding the medicine, and understanding the patients and what they're going through and what specific experience might help them with whatever context they're going through. So that's what we're covering on today's episode of the Voices of VR podcast. So this interview with Brennan happened on Friday, October 9th, 2020. So with that, let's go ahead and dive right in.
[00:02:14.857] Brennan Spiegel: My name is Brennan Spiegel, and I'm a physician. I'm a professor of medicine and public health. I direct health services research at Cedars-Sinai Medical Center in Los Angeles, where I also run our VR program. And I'm also an assistant dean at the medical school at UCLA.
[00:02:33.445] Kent Bye: Okay, great. And so maybe you could tell me a bit more context as to your background and your journey into working with virtual reality.
[00:02:41.143] Brennan Spiegel: Yeah, so primarily I'm a physician, a research physician, and my background actually has nothing to do with virtual reality. It has more to do with what we call health services research, which is all about how do we maximize the value of healthcare that we deliver? How do we do it in a way that improves patient outcomes and does it at the lowest cost possible at the same time? So I'm interested in health economics, But I'm also interested in innovations that could improve the delivery of healthcare. Now, I've also been interested in technology for a long time and have been working in digital health broadly, using wearable biosensors, for example, creating mobile health applications and so on. But I hadn't really even heard of virtual reality until, I don't know, five or six years ago. when Walter Greenleaf, who you may know, professor up at Stanford, came down to my lab and he introduced me to VR. And he said, you know, we've been using VR for decades in psychology labs. And we know based upon hundreds of studies that it has this uncanny ability to drive positive cognitions if it's used correctly and change people's lives even. But it's not really being used in health care. And I'm sitting there listening to this thinking, well, that sounds great, but unlikely. But he put the headset on me and I jumped off a building. And that's when I realized that, oh my God, this really hijacked my brain. I mean, it commandeered my brain. And I realized, wow, if we can use it for evil things, like jumping off buildings, then maybe we can use it for good, like helping patients feel better or get through a hospitalization. And that was the beginning of what's now a five, six year journey and over 3,000 patients at Cedars-Sinai, where we've been using VR for a wide variety of conditions.
[00:04:33.850] Kent Bye: I know Walter Greenleaf's been involved in this community for a long while, probably 25, 30 years now. There's been this whole research community in medical VR. Maybe you could talk a bit about your book, because there's been all this research that's been out there. Now that we have consumer available VR, you're able to actually start to be able to deploy it. But you also told the story in a way that I hadn't really seen before. Maybe there's other books like that that have done this, but this seems to be a really comprehensive survey of like, okay, here's what has been going on in this field for a long time and trying to tell the story for all the different contexts and applications. And so maybe you could just give a bit more context to this book, VRX, and how that kind of came about after your initial explorations within virtual reality.
[00:05:22.614] Brennan Spiegel: Yeah, absolutely. Well, VRX is, sure, it's about virtual reality, but it's about a little bit more than that. It's sort of what does VR teach us about our consciousness? What does it teach us about the way the mind and body are connected? And what does it teach us about advances in neuroscience and psychology that we can leverage to help not only with anxiety and depression, but even with dementia and schizophrenia, eating disorders, stroke rehabilitation? I mean, the list of use cases for VR and healthcare goes on and on. And so I start the book by recounting an experience I had at the University of Barcelona in Mel Slater's laboratory, where I have this out-of-body experience, a complete out-of-body experience in virtual reality. And I remember it to this day, it was so indelible. It's hard to even describe what it's like to be detached from your physical body. And as I'm sitting there, I'm thinking like, when did I get into the matrix? I mean, somehow it was like this brain in the vat experiment. that Hilary Putnam made famous. I was a philosophy major, so I've given a lot of thought to philosophy of mind and what is the nature of consciousness. And I thought, what is it about a computer that can violate something as essential as my physical coordinates in space so easily? And what does that tell me about my consciousness? So I start the book with that story of having this out-of-body experience. and trying to break down what happened in my brain and why, you know, what is the science behind that? And once I sort of try to break down what happened, try to sort of build it back up again, how can we use those principles of consciousness, or at least what we think is consciousness and how to manipulate it in a positive way to improve the health and lives of our patients. And the book is really a story of the science. And now there's been over 5000 studies. So, you know, getting this out into healthcare is no longer a scientific feat. We don't need more science at this point. And I sort of end the book by talking about what are the remaining barriers? It's really trivial stuff. Important, but trivial in a way. Like who's going to do it? Who's going to staff it? How do we clean these headsets and make sure they stay clean? How do we pay for this? But science really isn't the issue anymore. So I talk a lot about the interplay between neuroscience, psychology, clinical medicine, technology, and philosophy in this book, which is about VR. But as I said, it's about a lot more than that.
[00:07:55.350] Kent Bye: Yeah, I really appreciated that philosophical bent and having studied with Daniel Dennett, I know he has a very specific philosophy of mind and his approach of eliminative reductive materialism of really saying that we're just like these physical entities. But I think there's these different aspects of both the biopsychosocial model of health, but also embodied cognition, which I don't know if that starts to maybe contradict this trying to reduce things down into like these physical elements, but there's these other aspects of both the emotion and social aspects of medicine that, you know, I don't know if you've gone through your own evolution since you were a philosophy major, you know, studying with Daniel Dennett, and maybe you could just talk about that journey because it does seem like there's an expansion that's happened within the medical field over the past 50 plus years, but also the role of looking at these other aspects of emotion and your consciousness, your perception and your social relations.
[00:08:49.647] Brennan Spiegel: Yeah. Well, there's a lot in there and, um, I'll try to unpack it a bit. So, um, well personally, you know, I was a philosophy major, as you said, and I studied with Daniel Dennett and those who don't know Daniel Dennett, just look them up and watch those Ted talks and listen to him for a bit. He is a strong headed, materialist and, you know, is in the atheistic camp along with people like Sam Harris, although Sam Harris has more of a spiritual bend to him than somebody like Dennett. And in any event, you know, he influenced a lot of how I think, although when I first encountered him, I was very theistic myself and he kind of beat that out of me. And I came out the other end, sort of a curious materialist willing to allow for spiritual experiences. without that having to violate any physical laws of nature, right? Those are not incompatible. We can have spiritual mystical experiences without having to invoke a deity, for example. So without getting too far afield, you know, I do address that a bit in the book. And how is it that that out of body experience I had could feel so mystical? what was happening in my brain for it to feel so spiritual. And I try to talk a bit about the neuroscience of that and the idea of the kind of ruminating mind in our brain, in our mind, that's constantly judging, thinking, critiquing, setting parameters. And when we inhibit that, we're able to have this lateral thinking where we start to break through our traditional ways of thinking about the world. And that, by the way, is a very useful treatment for depression and anxiety. It's also the goal of meditation, the goal of psychedelics, and maybe cyberdelics. So I talk a bit about VR as a digital psychedelic and go through some of the literature on that as well. But there's also another part to your question, which is the evolution of medicine itself and its willingness to accept the spiritual domain of healthcare and well-being. And I trace the history of that a little bit in one of the chapters of the book, where I talk about how After World War II, when the World Health Organization was founded, in the Charter Constitution, I think it was 1947, when they wrote this, they talked about a definition of health that has stood to today. And it's that health is a complete state of physical, emotional, and social well-being. It's not just about physical health. It's about biopsychosocial health. And that was really an innovative definition at that time. But what happened in the mid-century with incredible advances in science was that a biomedical model started to kind of become preeminent. And that meant that we could reduce illness to boxes and arrows, you know, to receptors and hormones and chemicals. And we started to kind of lose track of the psychology of healthcare. And in fact, psychology itself was almost considered not a field of medicine, but a fringe field. But then, you know, decades later, Engle created the biopsychosocial model and formalized it. And he said, listen, we're missing something. The biomedical model is terrific, but it's not complete. we can't understand everything through this reductionistic approach to medicine. We have to understand psychosocial well-being too. And long story short, the pendulum has really swung back now. And now there's this, I mean, I'm an assistant dean in our medical school at UCLA, and I'm amazed every year at how many of our students are going into psychiatry. And it's become neurosciences and psychiatry has become completely legitimate. I mean, it's absolutely inspiring to see how many bright young people are choosing to go into psychiatry. And what we're talking about today are psychological interventions that have effects on the body. Because the last thing I'll add to this little discussion is the mind and the body, guess what? They're connected. And this old Cartesian notion that the mind and the body are separate and distinct, it turns out is just absolutely wrong, which gets to the embodied cognition idea you brought up, which is that we feel emotions in our body. And those feelings in our body go back up into our brain and we interpret them. So if we affect our body, we affect our mind. And it's not really a big mystery that that's the case.
[00:13:00.928] Kent Bye: Yeah, the thing that I find interesting about virtual reality as a topic to cover since I've done over 1500 interviews now over the last six and a half years is that there's so many different lenses to start to look at the technology in different contexts, different use cases. But at the end of the day, it comes back to us as humans, our consciousness, our perception, and how it seems as though there's different fields that are interrogating that to different degrees with that storytelling architecture, you know, video games, entertainment. enterprise applications, but the medical field in particular, I think is probably the most advanced in terms of trying to break down the mechanics of the combination between neuroscience or perception and some impact on our bodies. And with these different medical conditions, it seems as though you can start to see if you have some sort of deviation, there's some extremity that is happening, that is happening in your brain that is deviant from maybe a baseline. And that you're able to perhaps find some neurological correlate to that through neuroscience lenses and all the different tools to do that. But with VR is able to actually start to intervene and give some real therapeutic effects. And then as a result, you're able to potentially learn something that is not just applicable to them, but something that's like a universal principle for how the human mind works. Because if people aren't interested in medicine on its own, I think there's deeper principles here that you can start to learn about these universal principles of perception in the body and what we know and what we don't know that could be applied in other domains that are not specific to that. So I think that's why I think this book in particular is so fascinating because the medical field is on the bleeding edge of all these intersections and to see like what's even possible with the technology, but also just how the mind works.
[00:14:49.256] Brennan Spiegel: Yeah, absolutely. I think you've hit it on the head. And, you know, in medicine, we're always interested in what we call the MOA or the mechanism of action. we're scientists by training. So if we're going to use a new drug, let's say, a new therapeutic medication, we always want to know exactly how is it working? What receptor does it trigger or what biochemical cascade does it stop or whatever? We just want to know how it works. It's part of our willingness to even use a medicine is understanding how it works so we can have a kind of coherent picture in our mind and we can explain it to a patient. So the same applies to something like VR. People want to know, well, just how does it work? So we spend a lot of time trying to understand what is the mechanism of action of VR. And that's a Pandora's box, because to really understand it, we have to sort of understand consciousness. You know, we have, and that's despite Daniel Dennett writing a book called Consciousness Explained, we really haven't fully understood consciousness yet. That's still a mystery, and maybe for quite some time. But we are starting to pick a way at it. And in the book, I try to go through the different mechanisms of VR. And in different chapters, I break down these different mechanisms and talk about conditions that might benefit from certain mechanisms. And ultimately, I sort of describe four different mechanisms of action. One is to inhibit the ruminating mind, or another way of saying it is to achieve cognitive flow. They're sort of similar. And I touched on that earlier. And in the book, I talk about the neuroscience of flow, and the idea of the so called default mode network or DMN, which is a It's a network in the brain that is basically your inner babbling voice. It's kind of that ego self that we all carry around with us and lead us to believe we are a self. And it's amazing when that's inhibited what can happen. And that's the first mechanism that I talk about is the ability of VR to act like meditation. but without 40,000 hours of monk-like preparation, or like a psychedelic but without the pharmacology, its ability to inhibit the default mode network and reduce harmful ruminations. The second mechanism is about dampening inner pain signals. through a variety of sub mechanisms that I won't bore you with right now, I kind of talk about a bit in the book, this idea of distracting the mind from painful stimuli. So I talk about how VR is being used during childbirth, for example, it's being used for people undergoing bandage changes for severe burn injuries. how it's being used by dentists and by lots of different situations where pain is involved. I'm a gastroenterologist. So there's evidence that if you use it during a colonoscopy, it can reduce the processing of pain, both in the brain and maybe even in the spinal cord, which is really fascinating. So that's sort of the second, but then you get into these really interesting set of mechanisms, which is about back to the sense of self. either strengthening your sense of self or loosening your sense of self. Sometimes we need to loosen the sense of self because it's overbearing, like in the case of anxiety. Sometimes we need to strengthen the sense of self, like in schizophrenia, where there is a fractured or disintegrated sense of self. So anyway, I can go on and I'll stop there, but I talk about some of these mechanisms in the book and how they're being applied to really manage some of the most difficult conditions in all of medicine.
[00:18:13.815] Kent Bye: Yeah, I'm wondering if you could elaborate also on the gait mechanism, because that was interesting to hear, to see how there's these pain receptions that are being sent to the brain. And it almost feels like that sometimes our body can get into like these loops and that somehow VR is able to disrupt those loops and keep our working memory occupied and, you know, change your sense of time. Like maybe you could just talk about how do you think that the distraction therapy, the pain management applications of VR, what's the mechanism there?
[00:18:42.100] Brennan Spiegel: Yeah, absolutely. So there's a few ways we think it works. And you mentioned a few just there. So the first one, which is maybe the easiest to discuss first is this idea of distraction. Neuroscientists might call this inattentional blindness, which is just a fancy way of saying distraction. And the idea here is our brain can only keep track of so much at once. As we're sitting here talking, I'm not keeping track of how many times I blinked in the last minute, how many times my heart beat, the pressure of the floor on my feet. I happen to be standing right now. I can't keep track of that stuff and have a conversation with you. That's very hard to do. So similarly, if somebody is going through a painful experience, And all of a sudden, their eyes are bombarded with this fantastical visual environment of being on a beach or flying over fjords in Iceland. The brain literally just doesn't have the bandwidth to keep track of those two things at once. So we have this attention spotlight, which is directed by the prefrontal cortex, the part right behind the forehead. And that's kind of our executive functioning center. That's the part that really makes us human, among other things. But it tells us what we're going to pay attention to. And we can change our attention all the time. Some listeners right now might be bored for a second, and they're checking their iPhone. And that's fine. We change our attention all the time from second to second. So VR is an overpowering force when it's used correctly and can overpower pretty severe symptoms like pain. So that's the first mechanism. But the second is this idea of time acceleration. And this has to do with working memory, which you mentioned. And I touch on this in the book. And without getting into too much neurophysiology, the idea of working memory is we're constantly keeping track of the world around us, both in terms of our physical environment and the time that's elapsing. And sometimes if you drive home and you're in your head the whole way, you figure, how did I just get home? I don't even know how I drove home. That's called highway hypnosis, to the point where you can do all these complex physical skills that you don't even need to think about because you're busy thinking. So it turns out when VR occupies the brain, time can accelerate. And that's been shown for people going through bandage changes or childbirth. They feel as if it's almost half the duration of what it was. The third bit is what you described as the gate theory. And this is really fascinating. It turns out that our brain doesn't just haplessly receive pain signals, it can fight back. So the brain has this ability to send signals back down the spinal cord through what's called a descending inhibitory pathways and close these gates. They're almost physical gates, but they're kind of metaphysical gates. But without getting into the details, there's an inner neuron that can shut down along the spinal cord and block pain signals from rising up into the brain. So if you can get the brain into a calm state, the brain doesn't really want pain when it's trying to relax. But when it's vigilant, when it's anxious, it actually opens up those gates because it's constantly surveying your environment. It wants to know if there's pain so it can respond appropriately. But if we can put somebody who's anxious into a state of calm, those virtual gates will close and less pain will actually rise up in the first place.
[00:21:55.363] Kent Bye: Hmm. Yeah. And you mentioned a number of times, uh, having an opportunity to visit Mel Slater's lab in Barcelona. And I first came across Mel Slater's work in 2014 when Sebastian Kuntz was at the IEEE VR and tweeting a lot and started reading his blog. And I know that he was referring to a lot of. Mel Slater's theories on presence, but I've was so inspired by what was happening in the academic community. I went to the IEEE VR in 2015 and had a chance to meet Mel after he gave a keynote, did a brief interview with him and talked to him again later. But his work, I think is probably some of the most fascinating and interesting work with embodiment and all the different stuff of invoking the time travel illusion. And he's doing all these really sophisticated things of invoking this virtual body ownership illusion, and then just kind of messing with it in different ways. So I'm just curious, like how that came about for you to go travel to his lab and actually go through a lot of the different research experiences that he's been working on there.
[00:22:51.985] Brennan Spiegel: Yeah, yeah, you're absolutely right. He's been a real pioneer among others who I profile in the book. And he's been interested in the mechanisms of VR, getting back to our last presentation, the real science of it, not just the phenomenology of it, but the actual mechanisms of it. So I wanted to understand more about what it feels like to go through those experiences and to understand what's causing those experiences. And that's really, as I said, how I started the book. But while I was there, I went through a number of experiences that I discussed in the book. One of them, for example, was being on the receiving end of domestic violence, which is something I have seen many patients who have been victims of domestic violence, but I can't pretend to know what it's like to be a victim. But I have a little sense of it because I've been at least in a simulation of it in his lab where I was placed in a headset and with emotion sensors on my arms and legs. And then I look in a mirror and I see that I've become a woman and I am not myself, I'm somebody else. And with the one-to-one movement and the embodiment that he's able to achieve through a sequence of steps, I felt like I had embodied that avatar. And next thing I know, some man walks right into this apartment where I'm standing, and he starts to yell at me. He's screaming. He's yelling. He picks up a telephone. He throws it. He gets right up into my face. And as tall as I may be, he's taller. And no matter how tall the subject is, this guy's always going to be taller, looking down upon me and screaming at me and getting up in my face, telling me I look ugly. There was no physical violence in this. That's hard to simulate. But when I took that headset off, I was rattled. I mean, I was absolutely rattled. And what's amazing is he and his team have used that paradigm to actually help reform perpetrators of domestic violence in Spain. They've published one study with Mavi Sanchez-Vives, with whom he works, who led that study and showed that when they took perpetrators and exposed them to this, almost like a Clockwork Orange scenario, but more beneficent, I guess, they were able to demonstrate objective improvements in reading emotion on the faces of other people. So that's one example. And there's so many others that I talk about, like sitting across from Daniel Dennett, he put me in a room and I had a whole conversation with Daniel Dennett, where in fact, it was me speaking to me through the body of Daniel Dennett, which is this whole kind of self dialogue in VR, which is a whole other paradigm that's been used now for a number of conditions like depression.
[00:25:30.800] Kent Bye: Yeah. Maybe you can expand on like why you think that when you embody an avatar and you're looking at a photorealistic avatar yourself and you're talking to yourself through this third person perspective, like why is that different than just like self-talk? What aspect of embodiment there is actually giving some sort of therapeutic difference when you're have this experience of actually talking to a virtual representation of yourself?
[00:25:55.221] Brennan Spiegel: Yeah, I wish I knew for sure the answer. But you know, I think in general, the answer is this notion of presence, this idea that, you know, the brain, we're not evolutionarily designed to accept multiple realities at once, it's never been a requirement of our brain that we believe multiple realities are occurring at once. So as a result, we tend to accept the reality that we're given. And so I believe I'm in my body right now. But if my brain is convinced through sleight of hand that it's in your body, and I believe it, even though intellectually, I know I'm not really in your body, as opposed to children, by the way, who might actually believe it. And that's another interesting ethical discussion. But even if I intellectually know I'm not in your body, my brain doesn't care. It's like I'm in Ken's body now, or I'm in Daniel Dennett's body now. So I accept it. And there's something about the physical embodiment, the presence of being in this three-dimensional space, the one-to-one physical movements that make you believe that you are now that person. And what was so incredible to me is when I believed that I was in Daniel Dennett's body, because I was put into his avatar, and I discussed this in the book, I started to speak like him. I was able to think about how is he going to think about God and consciousness and dualism and all of these things that I had studied years ago. And I did a pretty darn good impression of Daniel Dennett. And it was almost like the experience tapped into this latent part of my brain that had been dormant for decades. But it was there and it became manifest like a ventriloquist, almost like a demon was speaking through me or something or homunculus maybe. And there was something about that experience that made me speak like him. And I was able to argue with myself through his persona, which was just spectacular and strange all at the same time.
[00:27:57.598] Kent Bye: Yeah, I know the Socratic method where you have like two people in this dialectic where they're really trying to like, cause you're limited by your own perspective. And that when you have gaps or holes in that perspective and you talk to somebody else, then Agnes Keller talks about how it's impossible to believe all truths and reject all falsehoods at the same time. And that you actually creates this dialectical process with two people collaborating towards a common truth. and that there's something odd about taking outside of yourself to speak to yourself, but you're still yourself, but you're just embodying it through the avatar, you're kind of able to recreate that dialectical process that allows you to escape your own perspective, which I think is not intuitive that that would work.
[00:28:37.903] Brennan Spiegel: Well, it's the basis of talk therapy. I mean, if I am depressed or anxious and I go to see somebody to help me, the whole point of that is to give me the headspace from myself so that somebody else can guide me in thinking differently about me. And it's not always successful, because I have to really trust this therapist. And they need to understand me. And they have to somehow get me out of my own mental ruts and routines that I'm so accustomed to. It is almost an existential crisis for me to somehow divorce myself from myself through talking with somebody else. So that's why talk therapy is not always successful. But the idea of the virtual talk therapy is, if anybody knows how to help themselves, it's often themselves. But they don't know how to actually get to that voice within themselves. And that's what it seems VR is able to achieve. So I talk about Chris Bruin's work in the UK, where he's taking people with depression. And he's put them in a room where they sit across from a young child who is crying and upset. And the goal is to comfort that child. And it's all in a virtual environment. And you have a first-person perspective of this child. You have to talk to the child and comfort them and talk to them. And then, unexpectedly, you switch and you become the child. And you look up and you see yourself, an avatar of yourself, comforting yourself. And this paradigm has led people to reduce their depression scores, not just immediately after the experience, but a month later. There's a sustained improvement in depression in a randomized trial. There's something about being in that experience where you realize we do have compassion for ourselves. We just don't always know it. And it's easy to give platitudes, like give yourself a hug and think good thoughts. And it doesn't always work. But in VR, it seems to actually work, at least sometimes.
[00:30:35.616] Kent Bye: I'm wondering if you could expand on this default mode network, because I know this is an issue that Michael Pollan covers and how to change your mind, sort of like the psychedelic experience kind of turns off that default mode network and allows you to have these transcendent mystical psychedelic experiences. But If you look at something like schizophrenia, if people have a deficiency of that default mode network, it could have this almost like you have these hallucinations or these voices. And there's really a quite provocative anecdote that you share of a use case of VR where there's actually like a psychiatrist who's embodying an avatar that's kind of almost tormenting somebody with schizophrenia within a VR experience. And I'm like, wow, that sounds like, how does this, how would that work to sort of like really fully embody these voices of terror. And then somehow that's going to make those hallucinations not as severe. Yeah.
[00:31:26.442] Brennan Spiegel: Yeah, you're absolutely right. Yeah, well, regarding this sort of spectrum of default mode network activity, there's sort of a Goldilocks zone where most of us operate, where we do have a sense of self. And that's really good. It helps separate us from the rest of the world. It's effective for strategizing, for planning, for executive functioning. If it gets too strong, it's called hyperfrontality. So the prefrontal cortex is too strong, then we might be caught up in our mind and ruminative and maladaptive. But if it's hypofrontal, where you have very little sense of self, then you lose a sense of your own personage in the world and voices start to interfere. And schizophrenia is part of the pathophysiology is that default bone network has broken down to some degree, there are breaks in the network. So, you know, that's not the entire explanation for schizophrenia. But anyway, yeah, so there's this sort of range of selfhoods from very, very strong and we need to loosen it to kind of weak and we need to strengthen it. And the example you're describing is Alexandre Dumas out of University of Montreal has been studying something he calls trial log therapy. So the trial log is a three-way conversation between the patient, the patient's hallucinations and the therapist. And the idea is that, you know, we all hear an inner voice, but we usually realize that's us. Schizophrenics are not so sure that it's them. It's coming from someone else. And it really can be really bothersome. So in this paradigm, the way it works is Dumais, who's the therapist, will work with the patient and try to create a sense of what does your demon look like? What does it sound like? What does it look like? And he can summon any kind of visual avatar you can imagine, a demon with horns, a frog, whatever you want it to be. So in the book, I talk about one guy who literally sees a demon who talks to him. So he's like, all right. He creates the demon. And he gets into VR, and he's staring at his demon. But what's amazing is the therapist is in another room on a microphone, and he's talking through that avatar. And his voice is permuted by the computer to sound like the voice that the patient hears. And at first, he mimics whatever that voice normally says. You know, you're a bad person, you're a bad husband, you're terrible, whatever it is. But over time, he trains the patient to fight back and to talk back to his demon. And eventually he starts to give way and to allow the patient to gain control over that demon in the three-dimensional virtual world. And he has shown in a randomized trial, it's way more effective than medications for reducing the severity and the frequency of hallucinations.
[00:34:19.085] Kent Bye: Yeah, it was at a conference last year. It was put on by Consciousness Hacking and they had this cross section of meditation, psychedelics, and technology. And Adam Ghazali was there and he announced his immersion vehicle thing that he's putting out where it's trying to create these biofeedback loops where you actually get into this like machine that is at the same time measuring all this stuff that's happening in your body and changing the immersive experience that you have. It looked amazing. Did you have a chance to try that out and maybe you could expand on what that was?
[00:34:51.706] Brennan Spiegel: Yeah. Even though I talk about it in the book, I have not tried it. The only one that I'm aware of is in a hotel in Maui or in Oahu or somewhere in Hawaii. It looks kind of like a Tesla for the mind, I guess. It's this pod, an immersive pod that you get into And it has a full visual, audio, and tactile experience, even olfactory. So you'll feel like you're on a beach. You smell the salt. You feel the wind. There's even a blanket that you put over your body that can move and change. And he calls it the unity effect. And the unity effect is a neuroscience principle that basically means that our brain is looking for simultaneous stimuli. So when you see somebody's mouth moving and the words are coming out, you think, oh, those are related. You know, the words are occurring with the mouth movement. But when you see a badly overdubbed movie, you realize, oh, there's something weird. It's not making sense to me. The brain can't compute. So the unity effect is if you can coordinate all of those stimuli at the same time, which he tries to do in this pod, then you will literally believe that you are on a beach or in a forest or wherever you are. And then he uses biosensors. So heart rate and heart rate variability or HRV, galvanic skin resistance, other measures of stress, anxiety, of physiologic function to try and allow you to change your physiology and then get rewarded for it with changes in the environment. So you have this sort of feedback loop, and you can learn how to control your stress, control your anxiety, whatever it might be, through this biofeedback. And VR is just a way to do it in a very immersive way.
[00:36:31.827] Kent Bye: Yeah. And there's this whole concept of the digit suitacles or, you know, cyber delics, maybe talk about the food and drug administration and how they are starting to see these types of therapies and if they're going to be regulated. I know Adam has always talked about some of these video games that are starting to be approved as a drug. So you would like to get a prescription from a doctor to go play a video game or to have a VR experience. And that seems like the direction we're going in is this kind of like experiential medicine where you're getting immersive experiences, but those have therapeutic impact. And so maybe just talk about how you see that evolving and the Food and Drug Administration here in the United States starting to like approve some of these virtual medicines.
[00:37:10.446] Brennan Spiegel: Yeah. Yeah. Yeah. So part of the reason I named the book VRX, it's sort of a play on words, but if VR is a therapy, then we need a VR pharmacy. As a doctor, I need to be able to reach into shelves of digiceuticals and pick the right treatment for the right patient at the right time. I wouldn't be a very good doctor if I gave everyone the same medicine, so I also shouldn't give everyone the exact same software program or VR experience. So that gets at this idea of different mechanisms, and how is the software working, and really trying to align the patient's pathology with the right treatment approach. And by the way, I wouldn't argue that VR alone is going to cure cancer or whatever. It's an adjunctive therapy for our traditional therapies. Although in some cases, it can really reduce the need for certain medications, like opioids. I have a chapter about that in the book. But anyway, the idea is that we need a regulatory landscape around this, and the FDA is starting to pay attention. And in fact, the FDA acknowledges that this is a new field of medicine, and they've given it a name. They call it MXR, or Medical Extended Reality. So that accounts for VR, AR, MR in general. And they're realizing this has real therapeutic benefits. So the question for startup companies and developers is, do you want your program to be for health and wellness, and you can put it on the Oculus Store or wherever you want? Or are you making a claim about true medical benefits, in which case it needs to be regulated and needs to go through a regulatory pathway? So our group at Cedars-Sinai, along with others, wrote up a document that was published on what are the steps developers need to go through to really validate a new regulated treatment option in VR. And I won't bore you with the details, but we have all these best practices, and I can put a link to that if people are interested. But what the FDA is looking for now is really evidence-based treatments. And some companies are really going down that pathway and trying to get their products regulated so insurance companies can pay for it and physicians can prescribe it.
[00:39:20.823] Kent Bye: And I'm wondering if you could expand on the use of body swap as a way to potentially change somebody's own body perception, whether it's anorexia and being able to have more accurate representation of your body, or if someone has a BCD and is able to maybe calibrate themselves to be more accurate of what their actual body size is. And so what's the mechanism there to do a body swap experience within VR? And then how's that change your baseline of your body perception?
[00:39:49.314] Brennan Spiegel: Right. Yeah. So, you know, we talk about virtual reality. There's also something called like internal reality and external reality. So we have from a big picture of two parts to our nervous system. There's the extraceptive system, which is, you know, measuring everything around us. What do you hear? What do you see? What do you feel? Then there's the interceptive system, which is monitoring that inner world within us. And there's some theory that eating disorders like obesity and anorexia occur when there's a breakdown in the interoceptive system. So for example, your stomach will tell you when you're full. And we know that. But at some point, the brain just ignores that and is like, well, I don't really care. I'm going to keep eating. And it's a complex pathophysiology. But part of it is just literally not mapping what you're feeling inside your body anymore, not recognizing that feeling. or I'm really hungry, the opposite, and not recognizing that feeling inside. It's a form of body neglect. And so the idea is, can we use VR to sort of overcome that interceptive blockade that has been described for certain eating disorders? And Giuseppe Riva in Italy has done a lot of this work. And I discuss it in a part of the book. where he does use this avatar body swapping again to give people a different perception of their body. And it was so amazing, and it's still mysterious to me exactly how it works. But if you take somebody who has anorexia and is very, very thin, and you ask them to take a piece of string, and without holding it up to their body, make a loop that you think represents the size of your waist. they will consistently take out far more string than is necessary, whereas people without anorexia will more or less get the right amount of string. So it's sort of an objective test of how well do you perceive your own body dimensions. And what Giuseppe Riva did is he put people with anorexia into VR, and they felt as if they were now in a normally proportioned avatar. And they look down and they see their body. And there's a series of technical maneuvers he goes through to create the illusion of embodiment. And they look and they say, oh, wow, that's what a normal body looks like. Oh, my goodness. And then they take them out. They have them reproduce that string test. And all of a sudden, they're better at estimating the size of their body. Well, that's all well and good. But what he has also done is shown that when people go through that paradigm, they can gain weight. And the opposite is true with obesity, where you under represent how big your body is. And he's shown in a randomized trial that this virtual embodiment can actually lead to sustain weight loss. So it's changing the way you perceive your body in a robust and durable way that might actually lead to behavior changes.
[00:42:35.449] Kent Bye: Wow, that's pretty amazing. Maybe you could go into a little bit of how you've been using virtual reality at Cedars-Sinai, because I know that you're also working with patients to some degree, doing the research and teaching and all this other stuff, but also seeing how it's actually deployed out. And I think that that's a big part of why this book that you've written is also so compelling is that you're not just looking at the research, you're actually like talking to patients and deploying it out for the last four or five years. And so maybe you could just talk about your experiences of what's it been like to deploy these out to actual patients.
[00:43:06.894] Brennan Spiegel: Yeah, yeah, definitely. So, you know, we've been talking about a lot of theory here and research, but does the research meet reality when we actually use it on the front lines of care? And so we've been interested mainly in pain management because it's such a pervasive problem, particularly in hospitalized patients. So we have one of the largest hospitals, actually the largest hospital in the Western U.S. with nearly a thousand rooms. And we have people with all sorts of different conditions, suffering from pain from cancer, from GI problems, from neurological problems, from orthopedic problems. So we have a large demand to use pain management approaches. So we've been studying it, and more than 3,000 patients now have used VR, some in research studies, some in more just everyday clinical care. And what we've learned is we need to have a virtualist. So the virtualist is a term I kind of made up, which is the clinician whose job it is to manage the VR. If we just leave a VR headset on the ward, no one's going to know what to do with it. It's going to get dirty. No one's going to use it. So we need somebody whose job it is to manage these things, to clean these things. So we use UVC light. We use an approved cleaning protocol. Now in the era of COVID, that's as important as ever. We have to debrief the patients, just like with a psychedelic. You don't just give them a psychedelic and walk out. You have to establish set and setting and debrief. So we have some approaches to doing that. And we also have to measure if it's working or not. And we've created a library of different VR experiences, because different people have different needs and different preferences. So we've done a lot of this work. We've also published a randomized control trial of 140 patients who were randomized between VR, it was a library they gave them, or they got to watch this health and wellness channel on the TV set, and the VR won. The VR beat out the TV, which may not be too surprising at this point. But yeah, I talk a lot about that in the book, kind of the nitty gritty of just doing this work.
[00:45:07.139] Kent Bye: Yeah. And the footnotes here are really quite impressive when you go through. And if you want to get just a historical overview, you do a really great job of trying to pick the authoritative citations, but maybe you could describe like how that may be a part of your day job of tracking the research and how you're able to kind of like funnel that process of medical research and applying to technology to be able to formalize it within a book like this.
[00:45:30.852] Brennan Spiegel: Well, I read a lot of studies to write this book and I had to be as selective as I could. I think I have about three or 400 citations or individual citations, but there are thousands of studies. And where possible, I tried to rely on randomized control trials and studies with higher levels of evidence, but that's not always possible. But I read hundreds of studies and I go through the literature every few weeks. I'll go through, I often use Twitter as it's sort of how I personally keep track of papers I find interesting. So I can just go through Twitter and it's like a durable reference for me and hopefully for others when I see something that's of interest. Cause this book, you know, is outdated the moment it's written. You know, I think the principles are not outdated, but the use cases and examples are every day there's new literature. It's incredible. So, you know, I could probably rewrite this book in two or three years and, and have four or five new chapters in it and, you know, 500 more papers. So it is a whole field of medicine and I'm trying to keep up. It's very hard because we haven't today talked at all about stroke rehabilitation and all the physical rehab opportunities, pediatrics, hypertension, it goes on and on. It's just amazing.
[00:46:43.222] Kent Bye: Yeah. And so I guess as we're kind of wrapping up here, one of the things as I'm reading a book like this is that it's a real reflection of human consciousness and perception. And because you do have like this background in philosophy, I'm just wondering if you feel like that at some point we're going to be able to actually use some of the technology to really get at the core of the nature of perception, the nature of consciousness itself. If you feel optimistic that we'll be able to get more towards this Daniel Dennett, it's all just physical stuff, or if there's a panpsychic interpretation, or if there's dualism or idealism. I mean, there's lots of different philosophy of mind approaches. and none of them are really falsifiable, but I'm just wondering if you feel like on this trajectory of looking at the intersection between medical applications of virtual reality, if you think we'll get a little bit closer of a philosophy of mind that's a little bit more comprehensive.
[00:47:33.249] Brennan Spiegel: I sure hope so. It's a tough question to answer. But part of what I hope will happen to help enable that line of thinking is that a new field of medicine will really come out of this. And MXR is as good a name as any. And that maybe in five years, there really will be virtualists. These are people who will be trained in medicine, but also trained in psychology, and maybe even in philosophy, and in technology. And this job doesn't exist yet, but it may very well exist in a few years. and whose job it is to administer and to rigorously study these interventions. Somebody like Mel Slater, who's done a lot to help us think about what this teaches us about consciousness, but who also has clinical training as well. I talk a little bit about that in the book. And what I also talk about at the very end of the book is You know, we're all living in a virtual reality every day. We all see things nobody else can see, hear things nobody else can hear. You know, that song that keeps playing in your head, no one else can hear it. We have dreams nobody else can experience. We live in virtual reality all the time. So the trick here is when somebody is vulnerable or distressed or doesn't have access to their imagination the way they might under normal circumstances, VR allows us to access that ability to imagine. And it allows us to leverage that ability to be creative and imaginative and hopefully in a way that is beneficial for well-being. And that's the clinical phenomena, but what's happening in the brain? We need a lot more research, functional MRI research, looking at cortisol and other stress hormones, understanding the neurophysiologic impact of these treatments on the body, and that may start to give us some insights into what's happening in the mind, and whether there really is something deeper that we haven't yet explored, and this might be a tool to help us get there.
[00:49:36.110] Kent Bye: Great. Finally, what do you think the ultimate potential of virtual reality might be, and what it might be able to enable?
[00:49:46.828] Brennan Spiegel: We have another hour for that one, maybe. But yeah, no, like I said, I think in health care, which is my focus, I really want to start seeing clinics that are dedicated to using VR. At Cedars-Sinai, we're working on developing such a clinic beyond just the research. Because the research is great. I do research. But what I really want to see is that we truly have VR as part of everyday care. And in the end of the book, I sort of go through a day in the life of the virtualist And it's a fantastical chapter, but at the same time, it's based upon technology that we have access to right now. Amazing stuff. Everything from using VR-based exoskeletons to help with spinal injuries, to stroke rehabilitation, to literally improving vision in people who are going blind. These technologies exist now. So we need to figure out, without getting too philosophical, just pragmatically at this point, How do we get this technology out to patients? I'm confident that it can save money, that it should be reimbursed by insurance companies, that it can improve quality of life. And we need to start doing that now and not just writing about it and talking about it.
[00:50:59.876] Kent Bye: Is there anything else that's left unsaid that you'd like to say to the broader immersive community?
[00:51:03.819] Brennan Spiegel: Well, I just want to thank you for a great discussion because I appreciate the philosophical twists that we've gone through over the last hour. And really that's the nature of this work. And I'm hoping more and more people in the VR community I recognize that, at least in healthcare, this is more of a social science than it is an engineering science or a computer science. I mean, I of course appreciate the incredible work that developers are doing, and I'm not a developer. And we need developers to keep doing amazing stuff. But in the end, this is about connecting patients and doctors to each other. It's about doctors understanding and empathizing with their patients' experience. It's a technology that, unlike other technologies that draws my attention away from my patient, this draws my attention towards my patients. And this is really about shared decision-making and offering new treatments to patients that never before existed. So it's a clinical science, it's a social science as I see it, and we're relying on the computer science, the engineering, but ultimately this is a whole new field of medicine.
[00:52:10.570] Kent Bye: Yeah, for sure. And all the immersive storytelling and the games, I think as time goes on, there's going to be more of these different design disciplines that are going to start to collaborate more and to maybe have therapeutic impact of specific stories or experiences. Yeah, well, Brandon, just thanks so much for joining me and for writing this book. It's a great recap of the medical field. I was able to learn about stuff I hadn't heard of before, as well as just, I think you just really tell the story of what's happening here. So if people want to get ramped up, but also just to see this combination, it's not just about medicine. It's like you said, it's about all these other philosophical neuroscience perception, the human experience, I think at the bottom line. So thanks again for writing the book and for joining me today on the podcast to talk about it.
[00:52:52.069] Brennan Spiegel: So thanks for having me. Appreciate it.
[00:52:54.360] Kent Bye: So that was Dr. Brennan Spiegel. He's the author of VRX, How Virtual Therapeutics Will Revolutionize Medicine. He's also a research physician, professor of medicine and public health. He directs health services research at Cedars-Sinai Medical Center in LA. He runs the Cedars-Sinai Medical Center VR program, and he's the assistant dean at the medical school at UCLA. So I have a number of different takeaways about this interview is that, first of all, Well, just the fact that it's all these different intersections that are coming together and creating this whole new field of medicine. The things that Brennan mentioned was everything from neuroscience to psychology, clinical medicine, technology, different implications of the mind-body connection and body cognition. different branches of philosophy, and specifically the philosophy of mind and looking at the mysterious nature of consciousness. Because at the very end, he said something that's very provocative. He said that healthcare is more of a social science rather than an engineering and computer science. And so there's all these other aspects of the bio psychosocial dimensions of our lives that go beyond just the reductive materialist physical interpretations of what's happening with our body, you know, the whole biomedical approach to medicine is actually changing quite a bit right now. And that in some ways, VR is on the leading edge of showing that there's whole other ways of looking at how we treat ourselves. Now, for me, I over time have gone more and more into this pluralistic philosophy, meaning that each of these different lenses give you some degree of insight into the nature of reality, but it's never the full picture. I think girdles and completeness kind of shows that whenever you try to constrain something into some sort of consistent logical system, it's going to be incomplete. And I think the biomedical model within itself is incomplete. I mean, certainly there's certain contexts where it's absolutely the thing that you want, but there's other situations and other chronic illnesses and maybe more mental health aspects, as well as stress and anxiety and your relationship to the wider world. not just an isolated entity, you're in a social context and your relationship to the wider social world, as well as your relationship to your own emotions, I suspect that as time goes on, they're going to start to unpack all these deeper roots of some of these issues and not just trying to attack the biomedical symptoms and try to mitigate those symptoms, but it could have deeper roots, it could be social roots, or it could be emotional roots. And I think That biopsychosocial model that Engel created back in 1977, as well as the World Health Organization's saying that health is actually a combination of the physical, emotional, and social aspects, I think that's really coming to bear with the implications of what this fusion of whatever ends up being called whether it's like the virtual therapeutics the digiceuticals or Cyberdelics or FDA is calling it medical XR. So MXR virtual medicine experiential medicine, whatever the name ends up being This is a whole new field that's bringing together all these different disciplines And that a lot of the research that is happening in the medical context actually has insights that can be applied back to the wider field of virtual reality, because it's really getting at the heart of our perception and how the mechanisms of action, the MOA, you know, what is the actual root of how some of this works? And Brendan went through at least three or four of those, and he's talking about how there's the inhibiting of the ruminating mind and really achieving cognitive flow in these flow states. And so in the book, he talks about some specific characteristics of that flow state, which is the selfless, timeless, effortless, and rich. And that's from a book called Stealing Fire, as well as a lot of research by Mihaly Csikszentmihalyi looking at these different flow states. But these flow states are able to create this cognitive flow that It's like the high challenge and your ability is able to meet that. And you are doing the tasks that you're able to do, but it almost happens at an unconscious level where you don't actually think about it. Your body is going through all those different actions. And I think the research that Brennan is trying to pull out is what kind of applications that type of cognitive flow could have in different conditions to sort of improve your well-being. Then there's other aspects of the mechanisms of action with the dampening of the inner pain signals. And so you're kind of distracting your mind and through a combination of unintentional blindness. And so you're kind of paying attention to other things, you're distracted. But there's also this descending inhibitory pathways. And so the signals from your brain that's like sending back into your body to say, you know, we're good, we don't need to like, be hypervigilant and worry about all these pain signals. And You know, if you're in a state of anxiety, then you may be actively looking for those pain signals, but your body can kind of get into this feedback loop cycle where you're maybe receiving more pain than you need to at any moment. And if you're in a relaxed state, then you can actually send these signals down into your body to shut off some of those pain reactions. And I think that's a lot of what the VR is able to do is kind of interrupt that default and kind of create you into a new baseline, which is pretty amazing when it comes to managing pain. and the other two aspects are sort of the dual aspect of the default mode network gives you the sense of self and you can either loosening the strength of the self so if you have hyper prefrontality and you need to you know maybe weaken that a little bit and deal with stress or anxiety in different ways then you can go through different experiences that maybe weaken that, or you could strengthen your sense of self if you have hypo-prefrontality, so it's a too weak, and so people with schizophrenia may not have that strong sense of self, and then as that weakens, then they could start to hear voices, and going through this whole performative experience, which is to battle your hallucinations that are embodied by your therapist, and so this is the trialogue therapy where It is both the patient and their hallucinations and the therapist. And together, they're working to try to reestablish these different relationships and strengthen the sense of self and to be able to fight back against these hallucinations within the context of this psychodrama, within this virtual reality experience. And then as a result, then they're able to have less hallucinations. And so they're able to see like these real therapeutic impacts. Another mechanism of action seems to be our internal perception of our body, the interoceptive system. And so you either have an accurate perception of your internal experience or an inaccurate. And so when there's deviations, then you can start to have conditions like anorexia. When you're overestimating the size of your body, then you start to starve yourself. Or if you're underestimating the size of your body, then you can start to lead towards obesity. And so what's amazing is that you could start to do these body swap experiences to calibrate yourself and to have these objective tests that help get you closer to your actual body size and sort of match the external and internal perception of your body. And that actually leading to being able to either gain or lose weight, depending on what condition you have. And so for me, that's amazing, just the fact that you can do a body swap type of experience and then have real clinical impact in that. But it also points to like the risks of doing these things. And maybe if you already are calibrated, then there could be ways to potentially uncalibrate yourself as well. So I think there's also potential risks there as well. There's also this very interesting aspect of stepping outside of yourself to comfort yourself. There's a couple of things that he had mentioned here. One was if you're comforting a small child and you then swap and then you're receiving that comfort from yourself, it's like being able to receive self-compassion. and then being able to receive self-compassion being an idea that actually leads to like helping to improve your depression maybe that's like opening up your mind to self-care or whatever that ends up being but to be able to care for an external entity that then you embody and then receive your own self-care which is a pretty interesting concept and then Also, when you're talking to the Freud character, or in this case, Brennan Spiegel's talking to Daniel Dennett, there's certain aspects of you being able to step outside of yourself, embody a new context, and from that new context, it's almost like being opened up to new concepts and ideas. And this actually reminds me of an interview that I did with Bernardo Castro back in episode 698 of The Voices of VR. And Bernardo is an idealist and so he sees that there's like one universal mind and that our bodies are more like receiving the consciousness that's coming from either this kind of platonic realm of ideal forms and that we're more receiving our consciousness rather than it emerging from our physicality. So one of the things that Bernardo points to is dissociative identity disorder where people within their own selves are able to kind of slip into these different modes of consciousness where you're able to actually like be blind in one identity and then another identity completely have different neurological reactions. And so this whole dissociative identity disorder is a bit of a mysterious phenomenon that happens in some people but what it sounds like when you go into these virtual reality experiences and that you're embodying yourself within yourself avatar, and then you embody another avatar, but you're talking to yourself and you hear the things that you said, but in another voice, and it creates this almost split personality where you're able to maybe tune into a whole mode of thoughts that go beyond your own context of your mind. It's almost like you're stepping outside of yourself and embodying somebody else to be able to reflect back to yourself. Which is what Brennan says is kind of the basis of talk therapy, you know, to be able to talk about your experiences and have someone reflect back to you. And then, you know, at the end of it, it may be the core of it that's universal between both of these is like trying to find an inner voice that allows yourself to heal yourself. But maybe you need to step outside of yourself to some capacity. And in this case, you're stepping into another embodiment that gives you a different context that allows you to maybe see and hear different things about yourself that you couldn't see before. it's almost like that pluralistic approach of the girdle who says, you know, you're consistent or complete, but you're able to kind of step outside of yourself and see like different levels of like the blind spots that you couldn't see otherwise. So that I think itself is very philosophically interesting and mechanisms of why exactly that works super fascinating, but when you listen to what Brendan is saying, it's like he's almost like tuning into a new channel of consciousness, or it was like a latent human potential that was always there, but he was able to like really embody the philosophy and concepts of Daniel Dennett. So just unpacking that a little bit and looking at Bernardo Kostrup's work in the dissociative identity disorder, I think there's some interesting parallels there that are worth considering in terms of alternative philosophy of minds that are not necessarily like in the mainstream, you know, idealism is not something philosophically that's really taken seriously that much. But I think there could be different insights when you start to look at these different types of experiences, and try to look at like, what is actually happening there, especially if they're able to do some neuro imaging in the mind to see what is actually happening in the mechanics of the brain when you get into these different modes of being. And the last couple of things that I just say, one is Adam Ghazali of sensing. He announced his sensory immersion vehicle on the 18th of May of 2019 at the awakened future summit. And I haven't been able to try it yet. But the idea of just having real time biofeedback fed into an experience where it has all these different senses at the same time, that's trying to create this unity experience that gives you a deeper sense of presence of actually being there. So matching your Sites you're hearing the haptic feedback as well as the sense of smell and being able to measure what's happening in your body and then actively feed that information into the experience to help to train you to Control your anxiety or your PTSD or whatever stress response that you may be having So that to me is super fascinating to see where that kind of line goes where you're in these sensory immersion vessels that are able to feed you all these different modalities of input and then your brain is kind of making sense of it and and to be able to feed back into it your biometric information and your heart rate variability and resistance and EEGs and all this stuff eventually to be able to create these feedback loops that really just like hack your consciousness. And this whole new field is the FDA is calling it the medical XR, digiceutical, cyberdelics, you know, experiential medicine, whatever you end up wanting to call it. It's taking virtual reality experiences and having real therapeutic impact. And like Brennan says, this is like a combination of so many different things. And in the future, I imagine that there's going to be other disciplines that are not currently in within the mainstream Western medical approach of trying to like align the right experience for someone at the right time, whether it's archetypal psychology, or different ways of looking at immersive theater and storytelling and You know getting at the heart of an experience where you're actually like a role-playing a specific character and looking at the different Archetypal dynamics of that character and maybe being the antidote to remediate different aspects that are happening within your psyche. So moving into the more biopsychosocial moving beyond just the biological lens and looking at the more emotional as well as the social dimensions and so what type of social context what kind of emotional experiences and could maybe shift these underlying patterns within these different symptoms that you're having. I think we're starting to see the very early seeds of that in very specific conditions, like schizophrenia, where it's using this type of psychodrama to be able to embody a character that at the end of the day is strengthening your sense of self, but you're doing it within this context of a Theatrical type of experience and so how much other healing aspects can this warping live-action roleplay? Stepping into stories like what other kind of therapeutic benefits might that have and I think we may be surprised over time to see How much this type of experiential medicine is going to feed into these core medical conditions that we have? Now, that said, that we're always going to have a role for Western medicine that is looking at that biomedical model and looking at the real symptoms that you have. And a big part of this is to measure and to see what works and what doesn't. And so doing these double blind studies and all this other research, I think, is a key part of as we move forward and not just abandon all that. But there's certainly a role. But there's also limits to that and certain conditions that fall outside of that Western medicine paradigm that may be looking to alternative types of medicine with this virtual medicine that starts to get into pain management as a frontline defense of interrupting those pain signals and being able to not rely upon something like opioids to reduce that pain, but other ways of doing it through these experiences that don't create these different addictive loops that create other epidemics of the opioid crisis that we have right now. So if you really want to dive into this field and get all the footnotes and everything, I highly recommend the VRX, how virtual therapeutics will revolutionize medicine. It's a fascinating journey. It does a great job of telling the story and really diving deep into the mechanics of what's happening within your body. And I think it may open people's minds in terms of what's possible and to see how you might be able to help expand some of the pro-social uses of VR and see if there's specific aspects of what you're working on could start to play out within the medical context. 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 enjoyed the podcast, then please do spread the word, tell your friends, and consider becoming a member of the Patreon. This is a listener-supported podcast, and I do rely upon donations from people like yourself in order to continue to bring you this coverage. So you could become a member and donate today at patreon.com slash voicesofvr. Thanks for listening.