The rise in mental health issues, such as depression, burnout, anxiety, and addiction, has led to the exploration of many novel therapeutic approaches (Hatta, M. H. et al, 2022; Glowacki, D. R et al, 2022; Viczko, J., et al, 2021). In addition to traditional methods such as psychotherapy, antidepressants, and electroconvulsive therapy, new methods such as psychedelics, neurofeedback, (Perez, T. M. et al, 2022), transcranial magnetic stimulation, electrical neurostimulation and new forms of non invasive neuromodulation (To, W. T et al,2018) and deep brain stimulation are being explored.
One such method is a non-traumatic psychotherapeutic approach developed by Dr. Milton Erickson, known as hypnotherapeutic-induced dynamic metaphoric therapy. While Milton Erickson (Milton H Erickson, 2009) was essentially pragmatic and goal oriented, he had no intention of creating a new theory in psychology. His method that acquired a reputation akin to fame, of being very effective with excellent and fast clinical results was based on clear principles such as working on a deep emotional and symbolic level and granting patients great autonomy in the therapeutic process. However, it also had limitations, such as the need for skilled hypnotherapists, the patient's willingness to participate in hypnosis, (a procedure often perceived as giving up control) and a lack of blinded and comparative studies that are needed to gain general academic acceptance. However, the utility of using metaphors (verbal images with transformative potentiality) is as basic to human psychology as axioma’s are to mathematics.
The method, currently described, called "Soulhacker," seeks to overcome those limitations mentioned above while maintaining the core principles of the Ericksonian method. By utilizing virtual reality technology and incorporating new innovative artistic elements, we hope to make this form of therapy more accessible and even more effective.
Virtual reality in Psychiatry
Virtual reality (VR), since 2005 also applied to the field of neuropsychiatry, (Sanchez-Vives, M. V et al, 2005) has a growing track record of successful applications in industry, the military, gaming, and medical domains such as revalidation both for somatic and cognitive problems. In psychiatry VR has been gaining momentum as a tool for treating mental health disorders, with a growing body of research showing its effectiveness in treating conditions such as post-traumatic stress disorder (PTSD), phobias, and anxiety. (Chirico, A,2017; Freeman, D A et al, 2017; Fodor, L. A et al, 2018; Geraets, C. N. W., et al, 2022; Li, B.-J et al, 2022; Mazza, M., et al, 2021; Wiebe, A. et al, 2022)
A PubMed search resulted in over 1,000 articles on the use of VR in psychiatry, with a small but increasing number focused on anxiety and affective disorders. Most VR applications in psychiatry to this date have been developed to aid cognitive behavior therapy, such as social and cognitive abilities, exposure therapy, PTSD, OCD, stress mediation, and pain relief. ( see Park, 2019 for review)
A 2020 review by Cieslik (Cieślik, B et al, 2020) of studies on the use of VR in psychiatry found evidence supporting the positive impact of VR therapy in psychiatric disorders, but the impact varies depending on the disorder being studied. The authors of the review emphasized the need for further research in this area, especially as VR technology continues to evolve.
Another more recent study by Hongqidi LI et al. in 2021 (Li, H., 2021) found that exposure to restorative VR scenery had healing effects on patients with mild to moderate depression. They found reduced anxiety, improved cognitive function, decreased counterproductive thoughts and a generally stimulation of positive feelings such as well-being and control.
How to measure the effect of VR on brain network dynamics?
The Soulhacker VR experience is a combination of artistically created visual scenes, somatosensory stimulation (IR lamp glow) and auditive elements (voiced guidance) all merged into a dynamic and metaphor rich world, intended to trigger generic positive emotions, reduce anxiety and depression and improve a general level of well-being and relaxing self reflection.
While evaluation of mood is generally done using semi structured self reporting on valence, arousal en control (dominance) the ultimate goal is to evolve toward a more objective direct analysis of mood as reflected in brain electrical activity (Apicella, A. et al, 2021). With that goal in mind, we collected besides the analog mood scores (SAM: Self assessment Manikin) also 19 channels of qEEG recordings of 5 minutes eyes closed before and after the VR experience.
The use of Current Source Density (Laplacian transform of surface EEG voltage time series recorded at the scalp) is a new tool in EEG analysis made possible by the use of the (family of) Loreta algorithms. Kamarajan et al discussed its usefulness in diverse psychiatric disorders. (Ishii, R., et al, 2018 ; Kamarajan, C., et al, 2019; Pascual-Marqui R.D et al, 2014)
In a pilot study in 2018 Tarrant (Tarrant J L et al, 2018) used quantitative EEG analysis to compare relaxation induced by VR to a simple state of quiet rest. Using current source density (sLoreta) analysis, the authors found that the VR induces a shift to lower beta power especially in the anterior cingulate cortex (part of the salience network and congruent with a reduction of anxiety. (Sadat-Nejad, Y et al, 2021; Zhang, Y et al, 2021)
"While spectral band analysis of EEG recordings in meditation specialists (Faber, P. L et al, 2012; Jerath, R et al, 2012; Kim, J.-Y., et al, 2019) tends to show that relaxation is related to an increase in alpha and theta power, modern electrical neuroimaging techniques that can calculate generating sources from surface-recorded EEG voltage time series provide a better understanding of the changes VR experiences can induce in brain dynamics. Current source density estimation methods (such as swLoreta, the newer weighted sLoreta variant (Palmero-Soler, E et al, 2007) offers better temporal and spatial resolution (deep sources) and hence allow for a dynamic view of brain networks related to higher cortical functions and emotional regulation.
In a recent study published in the journal Psychophysiology (2022), (Xu, X et al, 2022) quantitative EEG analysis techniques were applied to compare power spectral density and an increase of power in the beta band (11–30 Hz) in the parietal, occipital, and frontal lobes was identified. This was higher with 360° surround video immersion than with simple 2D VR screen watching. They also observed increased fronto-occipital functional connectivity with parietal and temporal networks. The authors conclude that immersion in 3D space has a more robust effect on visual attention, visual perception, and other visual-related cognitive information processing processes."
On safety and ethics in the use of VR in psychotherapy
As VR is a powerful technology, its use with psychological vulnerable patients justifies a separate discussion of some important ethical aspects of its implementation (Kellmeyer et al, 2019). VR is not without potential side effects, such as simulator sickness, balance problems and falls, derealization, visual irritation, or the danger of triggering affective or mental decompensation and even panic attacks or psychotic reactions. Therefore, its use with patients with depression requires extra care and close expert psychotherapeutic supervision.
The assurance of patient safety on both the physical and psychological levels were important ethical cornerstones in the Soulhacker study. At the level of ethics, we ensured the presence at all times of a trained neuropsychiatrist and a technical assistant who (invisibly to the patient) were present to assure his/hers physical safety (fall and collision prevention). We explicitly stress that VR is not meant as a replacement for psychotherapy, but only as an add-on tool in a psychotherapeutic framework. Respect for patient choice, physical and mental safety, and a strong focus on patient agency were the main, non-negotiable ethical principles of this project. Even when taking off the HMD at the end of the VR session, care was taken to do so slowly, to make the transition from VR to the real world as progressive as possible, without inducing vertigo, unsteadiness, or anxiety.
Keeping the sessions short (15 minutes) without sacrificing the therapeutic and metaphoric strength of their content, embedding continuous auditory therapeutic presence, allowing patients full autonomy while exploring and interacting in the VR world, granting them a safety first form of agency and control in movements and actions that change their VR environment from a dark and gloomy place to a mood-uplifting, sunny, and colorful scenery, and avoiding simulator sickness by coupling each movement in the virtual world to a one-on-one corresponding movement in a large physical space (empty space) makes this Soulhacker study innovative. In our study group of 27 patients, there here were no physical nor any mental negative side effects.
GOAL OF THE STUDY
While incorporating the core ideas of Ericksonian metaphoric hypnotherapy into a virtual reality environment, Soulhacker adds free body movement to the VR scene, grants patients a high degree of agency and autonomy, provides physical and psychological safety (fall prevention), and uses a non-directive, psychotherapeutic voice guidance during the session. A professional actor trained the psychiatrist in setting up the language needed to induce a feeling of comfort and safety while granting complete autonomy, or "freedom," to the patient. Directives such as "go there, do that" were avoided. Instead, patients were "invited" to freely try this or that, and changes to the VR environment caused by patient actions were labeled as "patient creations." Language was carefully selected to be in sync with this general principle. Granting agency to patients reflects ethical concerns and respect for patients autonomy which is be considered as the hallmark of modern social psychiatry.
The primary goal of the study was to see if positive mood upregulation could be correlated to dynamic changes in brain hubs and networks (at the source level) using swLoreta qEEG analysis of pre- and post-EEG recordings."