Elizabeth McMahon: Virtual Reality Therapy for Anxiety and Fear
Kim Bullock M.D., Jessica Hagen, and Faaizah Arshad speak with clinical psychologist Dr. Elizabeth McMahon on virtual reality’s applications for overcoming anxiety and fear, patient responses to immersive therapy, precautions clinicians should take before implementing it into their own practice, and her hopes for the future of XR technology in psychiatric care.
BIO
Elizabeth McMahon is a clinical psychologist who specializes in helping people overcome fears, phobias, and other anxiety disorders. She was an early adopter of virtual reality for therapy and has been using VR with clients since 2010. Her books include Virtual Reality Therapy for Anxiety: A Guide for Therapists, a self-help workbook, Overcoming Anxiety and Panic interactive guide, and a chapter on “Using Virtual Reality to Treat Anxiety” in the book Digital Delivery of Mental Health Therapies. In addition to her private practice, she teaches continuing education workshops to train therapists on anxiety treatment, including the use of VR.
The following is a transcript of the episode:
Kim Bullock
Hi there. Welcome back to Psychiatry XR, where we are on a mission to inspire worldwide conversations and innovation around the use of extended reality and psychiatric care. I'm your host, Kim Bullock, and I'm a clinical professor and XR researcher in Stanford School of Medicine. I'm board certified in psychiatry, behavioral neurology, and neuropsychiatry, as well as lifestyle medicine. But please note that this podcast is distinct from my own clinical, teaching, and research roles at Stanford. The information provided is not medical advice and should not be considered or taken as a replacement for medical advice. I'm excited to be joined by my two co-creators, Jessica and Faaizah.
Jessica Hagen
Hi, Kim. Hi, Faaizah. I'm so glad to be here. I am a healthcare reporter and co-founder of Collective XR, and our other co-creator is Faaizah Arshad.
Faaizah Arshad
Hi, Kim and Jessica, looking forward to this exciting conversation on our episode today!
Kim Bullock
Yeah, so am I. So we've created Psychiatry XR, which is a monthly podcast for all XR and behavioral health stakeholders including clinicians, researchers, allied professionals, developers, investors, patients, and just plain anyone fascinated by the ways in which evidence based mental health and technology intersect. And so in each episode, we invite a new guest to shine light and insight into the potential benefits, challenges and questions around immersive technologies and mental health. So for our episode today, we are truly delighted to have a very special guest: psychologist and pioneer VR clinician, Dr. Elizabeth McMahon, who has been one of my clinical supervisors. And we're hoping that our conversation today with Dr. McMahon will give you some insights into how extended reality is being used and taught to clinicians treating anxiety disorders. Dr. McMahon is a quintessential clinical psychologist who specializes in helping people overcome fears, phobias, and other anxieties. She was an early adopter of virtual reality for therapy and has been using VR with clients since 2010. Her instructional books include Virtual Reality Therapy for Anxiety: A Guide for Therapists, a self-help workbook: “Overcoming Anxiety and Panic interactive guide”, and a chapter on using virtual reality to treat anxiety in the book called Digital Delivery of Mental Health Therapies. In addition to her private practice, she teaches continuing education workshops to train therapists on anxiety treatments, including the use of VR. Thank you so much for joining us, Dr. McMahon.
Elizabeth McMahon
It's my pleasure. Thank you for inviting me.
Kim Bullock
So Dr. McMahon, can you share a little bit about yourself to our listeners, maybe some things, I don't think I've ever even taken the time to ask you even though I've known you for a long time about, what made you first interested in psychology? And when and why did you start using VR for psychological care?
Elizabeth McMahon
I started out majoring in music or English and decided that what I really wanted was what touched people's hearts and souls, which was psychology. It's a wonderful mix of emotion and intellect. You combine scientific research with empathy, and intuition. And I developed a specialty in anxiety because over time, the research just kept showing that we had effective treatments. And I've been using VR since 2010 because I came across this research literature that said, exposure using virtual reality was as effective as the gold standard, proven effective approach of exposure in real life in vivo exposure. So I was like, Oh, I've got to have that, I’ve got to have that for my patients.
Jessica Hagen
So, it sounds like you've seen it evolve quite a bit. How has it actually evolved since you began using extended reality and treatment?
Elizabeth McMahon
Well, there's been a great increase in the number of virtual environments, and the number of variables that you can control so that you can individualize and tailor the experience to help your patients to the maximum extent to optimize their chance of success. There are more companies that create VR or XR, specifically designed for psychotherapy. Equipments become more affordable. The faster pixel refresh rate means that there's much less nausea or what used to be called cyber sickness. There are more applications. They're even self-help apps although there are pros and cons to that. But it's been exciting, it's been exciting to see this grow: more research, more uses, more benefit.
Faaizah Arshad
Dr. McMahon, how do you use VR in your practice? Can you talk a little bit about how you've used it for your patients?
Elizabeth McMahon
That's a great question Faaizah, I'd love to. I've used augmented reality, mostly in treating insect phobias. But what I use most is virtual reality. And I love it because it has so many clinical applications. You can use it to help people learn and practice skills like diaphragmatic breathing, progressive muscle relaxation, mindfulness, focus of attention. You can help people achieve a sense of calm or peace, safety. You can help them feel grounded. You can help them self soothe, by having them go into virtual environments that they find calming, relaxing, or beautiful and pleasurable. You can lift mood. But by far, the most powerful and probably the most common use at this point is for virtual reality exposure therapy. You know, for controlled repeatable virtual experiences that help people overcome fears, and heal from the effects of trauma by gradually facing their fear situation safely, with active therapist support. And this can even be done remotely during teletherapy in video therapy.
Kim Bullock
That's so wonderful. Yeah. So I feel like, too, one of the challenges is getting clinicians to expose themselves to using this. So there's kind of getting them to accept and get less fearful about it. So one of the questions that's usually asked, and I wondered how you’d answer it and what you think is, How do clients usually respond to being introduced to virtual reality? Are they usually positive? Or when they're not, what kinds of skepticism or resistance comes up? Or anything else you think that providers should be mindful when they're starting to introduce VR to their clients?
Elizabeth McMahon
Clients are either enthusiastically eager, or willing with usually a silent reservation or skepticism, because the most common feedback I get is, ‘Oh, wow, I didn't think it would be this real.’ But the other most common feedback that I get is, ‘This really made a difference.’ They feel more confident. They feel like they make fast progress. Over half of my current practice is people who sought me out, because I offer virtual reality. People read about it, they hear about it, and they think it gives them hope that maybe they might truly be able to get over their fear of driving, their claustrophobia, their fear of flying— that it might really help free them from the construction and restrictions of fear.
Jessica Hagen
Do you think that virtual reality has been a beneficial added tool to your belt?
Elizabeth McMahon
Absolutely. It allows me to provide therapeutic experiences that are otherwise impossible. In virtual reality, I can control the weather. I can control the degree of turbulence on the plane. We can do take off over and over and over and over until you're comfortable. I can control the audience response, the size of the room that you're in if you're trying to get over claustrophobia. I can control the height at which you are in the therapy session, and we can go as slowly or as quickly as works for you. People seem to get over their fears faster. And we know that not everyone can imagine well, and that the ability to create vivid mental images declines with age and virtual reality simply takes care of that problem. I see what my patient sees. I hear what they hear. I speak with them so that on the one hand, they're there and the one on the other hand, I'm there with them in their head, guiding them supporting them. So my sense is they have they have a more lived experience of success.
Kim Bullock
Yeah, I mean, it's the embodiment of precision and personalized medicine. And I can't understand why more people aren't using it, you know? Yeah. So you can customize and personalize it and just meet the person where they are.
Elizabeth McMahon
Yes, I can treat, I can treat anxiety disorders without virtual reality. But why would I?
Kim Bullock
Right.
Elizabeth McMahon
VR makes it easier, faster, and in my experience more effective.
Kim Bullock
So are there any clients that come to you, maybe you have a selection bias because they're coming to you knowing that you're the world's expert on VR in psychotherapy, but do you ever get patients that just can't do it, and then you have to resort to just plain old vanilla exposure therapy.
Elizabeth McMahon
Of course, nothing's going to work for everybody. But I have to say that I can probably count on the fingers of one hand, the number of people who have just gotten too queasy or too nauseous. Or just somehow, like, my husband can't use VR, because there's something about his astigmatism correction and his glasses. He just can't get a good focus. But in, let's see, I'm in my 12th year of using VR with patients. And I'd say I have had fewer than five people who couldn't.
Kim Bullock
Is it mostly just because of the physical restraints or sensations that are disturbing?
Elizabeth McMahon
Yeah, yeah. Yeah.
Jessica Hagen
That's common with a lot of medicines, too. I mean, it's not that every single medicine works exactly the same for every patient.
Kim Bullock
Absolutely.
Elizabeth McMahon
Sure. Sure.
Kim Bullock
The rate of side effects is probably much less than a medicine.
Elizabeth McMahon
Well, and occasionally, people will say, ‘Well, my phobic trigger’ and they usually don't use those words, but you know, ‘what really makes me scared is not in the virtual environment.’ So for example, I had one person who said, ‘Well, what really scares me is the bump on landing.’ But on the other hand, if I'm seeing them in person, I can put them in a chair, and I can stand behind them, and I can provide that bump. Or, you know, put them in a put them in one of those recliner chairs and bump it.
Kim Bullock
Yeah, and I figure sometimes the reptilian brain, you might think you know what the prompter is, but it can be so implicit and context dependent that you're able to put the context there even while you talk about it. Or there's enhancements even if it's not the exact trigger prompter that that person believes it to be. It can still be additive in some way.
Elizabeth McMahon
It can, it can. And think about the things that, I mean VR lets you do things that you can't otherwise do. For example, right, if someone is afraid of blood draws or injections in VR, we can just have that provided. We can have them get a blood or an injection over and over and over and over again. While you'd blow out the veins. You can't do that in real life.
Kim Bullock
Yeah, the amount of repetitions and the dosage. We can get so much more of a dosage and I love it. Well, so in 100 years, how would you like to see extended reality being used in psychiatric and mental health care and what do you see as the challenges and things that we need to solve to get to your vision if you have one.
Elizabeth McMahon
I think my vision would be using it to treat more mental health issues. It's already being expanded. And they're exploring using it with body image issues, with eating disorders, with ADHD, with auditory hallucinations; expanding the uses to improve quality of life, to provide safe effective training, to connect remote work teams. I think, I think the challenge is to use it to facilitate, say, deep interpersonal connections in therapy and otherwise, not act as though it's some kind of a replacement. And that the real challenge the real goal is to use immersive technologies thoughtfully with unbiased evaluation of their actual impacts and effects. You know, what trainings what interventions, what technology, what interactions are best done through immersive technology? Which are best done in person and how can we safeguard? How can we take the lessons we've learned from social media and the internet? How can we put some safeguards in place to try to minimize the misuse of this tool? Because immersive technologies are not inherently therapeutic. It's a tool, not a treatment. And like any tool, it can be used to help. And it can be used to harm.
Faaizah Arshad
I totally agree Dr. McMahon, and how do you think that clinicians or providers can facilitate that improvement in extended reality for psychiatric or medical care?
Elizabeth McMahon
I would encourage, go to the literature, look at the research, understand how to use this tool, and look at how it fits with your current practice and with what you know, as a clinician. Take reasonable precautions before you use it, you know. Ask if there's a history of seizures. Check if they get nauseous, you know. Describe the virtual environment before you put someone in VR and monitor them. Stay actively engaged with them. But I would really say ask for research when a company or you see a new VR app coming up. Really step back and ask, who designed it? Did they use clinicians? Is it consistent with evidence based best practices? Is it consistent with what we know about mental health and with research? And keep asking, ‘What's your research support? Have you evaluated that? What are the data?’
Faaizah Arshad
Thank you so much. And did you have any remaining thoughts or messages that we didn't cover that you'd love to share with our listeners?
Elizabeth McMahon
Well, if you're a therapist, and this has intrigued you, I invite you to sign on to the Society for Virtual Reality Therapy website. That's svrt.org because you'll find there videos explaining and talking about and demonstrating the use of virtual reality to treat needle phobia and injection fears, as well as information about what's available clinically, and how to think through and decide what you might want to use and what would be appropriate for your clinical practice. I would encourage you to look into this because it's an incredibly flexible, useful, powerful, clinical tool.
Kim Bullock
Thank you so much. Yes, I think that website is such a gift to the world and has a lot of content that is available to all clinicians. And thank you for helping support that and for all you do. You're such a great mentor and leader in the field and give us all hope and are paving the way. So that's it for this episode. And this is the Psychiatry XR podcast and Dr. McMahon, thank you so much for sharing your perspective and insights with us today. We hope to have you on again, and you gave a very realistic and conversational dive into emerging XR solutions for us for mental and behavioral health. And thank you everyone for listening. This episode was brought to you by Psychiatry XR, the psychiatry podcast about immersive technology and mental health. And for more information about Psychiatry XR, please visit our website at www.psychiatryxr.com And make sure to subscribe to the podcast and tune in again next month to hear from another guest on XR and psychiatric care. You can join us monthly on Apple podcast, Twitter, Spotify, or wherever you get your podcast. Kim Bullock produced this podcast with the help of Faaizah Arshad and Jessica Hagen. And we credit and are so grateful to Austin Hagen for music and audio production. See you next time.