Dr. Kim Bullock

Welcome back to Psychiatry XR, where we aim to inspire worldwide conversations around the use of extended reality in psychiatric care. I'm your host for this episode, Kim Bullock, and I'm joined by my co-host, Jessica Hagen.

Jessica Hagen

Hi, it's so great to be here with you.

Dr. Kim Bullock

In today's episode, we're speaking with Dr. Jessica Stone. She is a licensed psychologist working in private practice in Colorado and a pioneering voice in the integration of technology and mental health. She is the CEO and CPO and co-creator of Digital Play Therapy and Virtual Sandtray for virtual reality, and an internationally recognized leader in using digital tools, virtual reality, and immersive technologies to enhance psychological services. She is a widely published author, including Integrating Technology into Modern Therapies: A Clinician's Guide to Development and Interventions, and more recently, edited and published a book titled, Mental Health Virtual Reality: The Power of Immersive Worlds. She is founder and chair of the Mental Health Virtual Reality International Coalition. In addition to her clinical work, Dr. Stone is actively involved in research and academia. She is a guest associate editor for Frontiers Virtual Reality and Pediatric Medicine, and an affiliate of the East Carolina University, College of Education Neurocognition Science Laboratory. Thank you so much for joining us, Dr. Stone.

Dr. Jessica Stone

It's really nice to be here.

Dr. Kim Bullock

I'm so excited to have you. Your work is super inspiring, and I'm really thrilled to have a chance to meet and talk with you today in more depth. Your unique career seems to really combine and span academia, clinical, and entrepreneurial skill sets. So, this podcast really likes to highlight the diversity of careers and trajectories, possibly for those interested in mental health and XR careers. So, I wondered if you could do us a favor, just kind of giving us a summary or a walk-through of your career history and how you ended up where you are.

Dr. Jessica Stone

You know, I don’t know exactly how I ended up where I am. I think it has a lot to do with being exposed to different things, just like probably anybody else of how you get into something. The short of it is that I've been in the field a little over 30 years and seen a lot of changes over that time for sure.

My focus has been really trying to identify the cornerstones of what helps people work through things, process it, understand it, and one that's different for different people. We're different. We work differently. We can do the work of clinical psychology in many different ways. So that means, as a clinician, it's important to have flexibility in that, so that’s like a cornerstone.

Then through being exposed to different modalities and interventions and then seeing the transformations in the world in terms of digital, putting those things together and saying, there has to be something here. How can I identify what's going to be therapeutically appropriate in the use, in the experiences that people are having? Then it just sort of exploded from there, when I started to see how much power was within.

Dr. Kim Bullock

So, did you as an undergraduate or earlier - were there signs of this interest going on, or did this happen in grad school? Or did it happen after grad school when you were a practicing psychologist?

Dr. Jessica Stone

Yeah, so when I was in graduate school, we didn't even have access to the internet. I'm old school for sure. I am definitely not a digital native. I am a digital immigrant, for sure. And when I did my dissertation, we bought a computer from a yard sale and hooked it up to AOL and listened to the noises – I won't try to mimic, and I could literally go make a sandwich and come back and it might have connected, you know.

So, no, it was not part of my undergrad or my graduate school. It wasn't part of my early career. It was something that, honestly, I think a big push of it was my own children. So, my oldest is going to be turning 28 here in about a month. So, when he and his brother were starting to get really interested in these things, I noticed that I was in the front seat of the car, and they were in the back seat having conversations. I had absolutely no idea what they were talking about. From that, I grew an interest of what is that? What are you guys talking about?

At the time, they were really, really into playing RuneScape. It's still around. But you know, old school RuneScape when it was relatively new. I decided to make an account. I wanted to know more about what was going on in their world and not be excluded. I didn't need to be in the middle of their conversation, but like they were speaking a different language, I had no idea what they were talking about, so I wanted to understand more.

What I discovered was, one, I'm not good at these games. So even though I live in this world, and I work in it, and I talk about it, and I play the games, I'm not very good at them. I found myself a little – I don't know if anybody's played RuneScape – wanting to stay away from the danger areas on the map, so I found a little village. I started to realize that feathers were a high-ticket item, and a lot of people didn't want to spend the time it took to get the feathers, and so I sat there, and I collected feathers, which essentially was killing chickens. Such a strange thing to say, but I just sat there, and I did that, collected the feathers. I would then have people come looking for me intentionally to buy feathers, because I had millions of them. Then I was known as the chicken lady, and people would log on and ask my kids, where's the chicken lady? Because we need feathers.

What it did was it really opened up so many channels. I understood more about what they were doing and also value. When I would say, hey, it’s time to go, or the stereotypical “get off that”, I was able to say “don’t start another quest, because if you start another quest, then it’s going to take this much time and we don’t have this much time.” This is a very different conversation than I would have had otherwise, without understanding more of what was going on. Then I saw the impact on our relationship, then it expanded out into, if this has that big of an impact in my family and my relationship with my children, it has to span out to all the other aspects of the work that I do, then it propelled a lot of that work.

Jessica Hagen

What about adoption? Was it difficult for you to kind of go from that game that you were playing to, like, adopting it within your psychology practice?

Dr. Jessica Stone

I don't think so. One, it was the language that the people who came in, you know, if they were digital natives, it's a language they spoke. And to have even that little, tiny, silly example of me playing RuneScape, never mind all the other games, but that one – for someone to come in and say, "Oh, I play this game," and for me to go, "Oh, I play the game too." I said, you know, and just they're like, "What? Wait, what," you know, then there's an instant connection. Especially for people who have had the experience of, "Oh, we're not going to talk about that in here," you know, like, that's an excluded part of your existence, in your life, and we don't find value in that. So we're not going to include it in here. And particularly children. But I mean, digital humans aren't children anymore. There are plenty of them who are right, you know, in their thirties.

Dr. Kim Bullock

What a fascinating story. Yeah, origin story. That's, I love that. Yeah. You took it all the way to this Sandtray, the Virtual Sandtray [app]. Are you able to tell us briefly or summarize the fundamentals of Sandtray and how it led to this App Store application?

Dr. Jessica Stone

Sure. And of course, I'm not going to do it justice, because I'm going to say it, you know, in a very small package, as much as I can. But basically, Sandtray started about 100 years ago. Dr. Margaret Lowenfeld, after World War Two, she noticed that there are a lot of people who either didn't have the words, you know, they were young, and they didn't have the vocabulary, or they had had experiences that were very difficult for them to verbally speak. And so she looked for a way for them to express themselves non-verbally. It doesn't mean you have to be non-verbal. It means you can be non-verbal.

So, she created basically a wooden box and put sand in it, and frequently it's painted blue on the bottom. So, if you dig down in the sand, it looks like there's water. And then you take miniature items, and you create what's called a world. And that can be from a prompt or not. It can be, you know, free reign, build whatever comes to you, but it's essentially a projective technique. So, it's taking that inner feelings, experiences, any of that stuff, and projecting it out onto something else, so that it's a visual representation, and then you can see things.

I'll be 100% honest, that when I was first introduced to sand tray, I didn't get it. I was like, "Okay, I'm going to put a bunch of little things in the sand, and that's going to tell you something about me, like, I don't get it." And I was in a training. I was the president of a branch of an organization, and we were providing trainings, and one of them was going to be sand tray. And so as the President, I needed to be present. And we all had these tiny little metal trays, you know, the ones you have for Thanksgiving, for the side dishes and stuff. We had those. And put some sand in it, went to the tables, picked out a few items, put them in the sand tray. And then everybody had to go around and talk about everybody else's trays.

Nobody in there – they knew of me, but they didn't know me. They don't know things going on in my life or whatever. And they came to my desk, looked at my sand tray, and they said a whole bunch of things that were true about me. And I was like, that's crazy. I need to really embrace this in a way that I haven't. This led to a lot of trainings and learning. That led to saying, hey, there are situations within which and people for whom the traditional tray doesn't work, and how can we expand that out? That's where the virtual version was born. Started that in 2011.

Dr. Jessica Hagen

How did you develop the virtual version?

Dr. Jessica Stone

I am married to somebody who knows how to. I got lucky because handy – never been able to do it otherwise. We've not been able to afford it. I mean, it's a very, very complex program with protections in place for use in therapy. We have a remote version where the client can be anywhere in the world, like it mirrors the fundamentals that were in the original sand tray from Lowenfeld and then has extra things on top of it. I mean, you can't have fire in your traditional tray in an office, but we have fire and explosions and dragons who fly and, you know, all of that kind of stuff.

Jessica Hagen

And can you add whatever kind of imagery you want to the sand tray pretty easily?

Dr. Jessica Stone

So, we have over 8,000 3D models available, so they can choose from those, and then they can put them in. We're actually doing a different program right now that includes a lot of aspects with AI and generative AI has so many possibilities, as we know, and I've toyed with the idea of putting that into the virtual sand tray, but I'm also pulled to keep it as close to the traditional as possible. It becomes something different when you take it in too many directions. My personal jury is out on whether or not I want to do that. That makes sense.

Dr. Kim Bullock

Yeah. Well, the thing that grabbed my attention, what I really wanted to talk to you about as well and get your thoughts and opinions on and was your publication, the Mental Health Virtual Reality: The Power of Immersive Worlds. And just congratulations to you on that. I thought it's a great contribution to the field, and we needed something comprehensive, and wondered if you could tell us a bit about what's included in that book. Again, summarizing, I know it's not doing it justice, but who your target audience is, and maybe the process of editing it, you wrote parts of it, and then a leader and putting it together.

Dr. Jessica Stone

Yeah, editing a book, it's interesting, because a long time ago, I thought, why is that person's name on the cover of a book when they didn't even write all the things that are inside of it? And then when I started getting into writing and started editing, I was like, “Oh, this is why.” And it's not just because of the amount of work, it's because of the orchestration of the idea. And then you're finding people, you know, the hope is, obviously are going to meet those needs that you're looking for to bring together. And then there's the work of the actual editing. And you have the big picture. You know, each individual author really has their picture, their smaller picture, but it's been quite an evolution, even for me in that process.

But I wanted to write this book, or have this book written, edit it years ago, and honestly, I couldn't find enough authors, not enough people who were interested, but enough people who had the combination of the expertise of the knowledge and the familiarity with the research and actual experience and doing not just this academic idea of this could be done. So, I had to table it for a number of years. And then as I made more and more connections and the mental health portion of the XR community grew, and then it was like, okay, now it's time to bring this book back to life.

And I'm not going to do it justice in saying there are a lot of different arenas, anything from UX development for accessibility, which is one of my most favorite chapters. And I think it's just such a hugely important - we could do hours of conversation just on that in and of its own. Of course, I wrote a chapter on using it clinically. There's a chapter on neurodivergence, work that is being done in Ukraine, pediatric cancer patients, suicidality. I mean it really – I worked to find experts and people. People who really could contribute something in the cornerstones, and then even in some of the niches that come to play in mental health treatment.

Dr. Kim Bullock

Who was your target audience?

Dr. Jessica Stone

I mean, I want to say anybody and everybody. Really the target audience primarily are people who are in the different fields, who are looking to integrate XR of any type into their treatments. Whether that's medical, that's mental health, I see them as being very much a Venn diagram. You know, you - we're human, yeah, you're gonna have mental health in anything that we're doing, right? I hope is valuable for either people who are already in those areas or people who are looking to integrate it in and to see all the ways this can be integrated powerfully into our work and for clients or patients, depending on your environment.

Maybe the specifics, you know, like the deeper academic portion of it, might not be of interest, but even to be able to read it and to say, "Wow, I have struggled with this. I didn't realize all the ways that XR could help me processing or feeling better, getting better, you know, whatever is the need for that person." I really think it spans more than an academic book.

Dr. Kim Bullock

I was thinking that industry often needs to be informed when they're developing or they're startups, and they might not be clinicians, but they're wanting to be in that space. And it was a good kind of summary, possibly for that audience as well. Or entrepreneurs, do you think?

Dr. Jessica Stone

Absolutely and different considerations when they're creating different programs. I served as the chief psychology officer for a VR company, and that was basically my job, was to take the mental health, the academic, the research, all of those pieces, and translate it to the development team. Say, okay, these are the experiences. This is the neurobiology of it. These are the environments. These are the sounds, the sites, the colors, the actual user interface. Being able to speak both tech and psych is a really valuable thing.

Jessica Hagen

Yeah, it's very rare. Yeah, I was going to say, you don't hear very often that there are chief psychology officers on any XR boards. So that's pretty impressive, that that's - one more. There needs to be more. I think that's really, really important.

Dr. Kim Bullock

I don't know any psychiatrist on any boards, either, so I was shocked to see in February your publication, because, in all transparency, our department is in the early stages of creating an academic text with American Psychiatric Association for university settings, or maybe as a basis of a curriculum focusing on mental health and immersive technologies, and we're hoping to create something that could kind of stand the test of time, because you probably know, things are rapidly changing, and the research is always changing, so it is hard to write a book. And I thought, oh my gosh, you've done it. You did what we were thinking of doing. So, we're thinking about covering a lot of topics that may be relevant in your textbook, but might overlap, of course, and we don't want to plagiarize or infringe on your copyright. And wondering if you had any suggestions or advice for us and what we could include that was not included in your book, that you think that we might do for our purposes as psychiatric text or, you know, in a purely academic setting. Do you think that there was anything that wasn't covered in your book that we could add to the field?

Dr. Jessica Stone

One thing you said is the concern about writing anything to do with tech, and I think I'm up to either contributing to writing or editing 46 publications now, and most of them are about something to do with tech and mental health. So, I live in this – I feel like I eat, drink, breathe, this concept that it moves so quickly, and how do you write something that's going to retain its relevance? And for me, it's getting down to the cornerstones. What are the cornerstones that basically stand the test of time when we think of like folk stories and whatnot. Why is it that we still know folk stories that were told hundreds, thousands of years ago? And it's because it speaks to the human condition and the human experience, and it stands the test of time.

So, I'm not saying like, this is going to be relevant in 1000 years, that's what I'm saying. That would be cool, though it's more like, how do we identify what those fundamentals are so that we can have things stand the test of time? So, one is absolutely that, but when you said that, the first thing I thought was, well, bring me on. I'll be happy to be part of doing that publication. One thing that we didn't really get into specifically and, we could have, but you're limited by words, right? And so, you have to choose carefully what you're going to bring into a publication that's going to be the most powerful for the reader and for the greater good, hopefully. We didn't get into specific diagnoses. We didn't get into you have this situation…these things might be.

Dr. Kim Bullock

Right. There’s anxiety and then some trauma that you could expand on the diagnostic criteria, right, and diagnostic categories.

Dr. Jessica Stone

Yes. And I think there's a lot of value in that. So, like, we do have that in there, like you said, we have a chapter on anxiety, we have a chapter on trauma, the suicidality, one, neurodivergence. There are a lot of areas where the authors have spoken to that, but not in the kind of detail that could be done in another text.

Jessica Hagen

Do you think that with as quickly as technology progresses, that it would be wholly beneficial to go into those details still?

Dr. Jessica Stone

Well, yes, couple reasons. One is that even if the platform, the hardware, the software, even if those things change over time, which of course they will and when that happens, if you can identify the essence - so a person who experiences anxiety, what is the essence of a program or programs that is going to hopefully help them work through things? It doesn't have to be that it's this particular headset or this particular program, but what kind of environment, what kind of interaction with that environment?

For me, it has so much to do with that level of immersion, and the more and more and more we can convince the mind and the body that they are actually in that environment and interacting in those interactions informed by research, clinical expertise, informed by all those things. But the more we can do that, the more it unlocks and activates the nervous system and the parts of the brain that will allow us to even enter into those arenas that help us process things without red flags going up all over the place saying, this isn't real. This isn't what you know - I just did a presentation at a conference, and my whole theme was, with great power comes great responsibility, borrowing from, obviously, Spider-Man, and then it really comes from the French Revolution. So, we need to respect the power and the responsibility that comes with it.

Certainly, having somebody's mind and body believe they're in an environment they're not actually in can be used for not good reasons. If we can hone in on what those components are and have those multi-sensory experiences, the power in mental health treatment is phenomenal, right?

Jessica Hagen

It's almost like sharing best practices, right? Like this is something that's already been proven, so this is a standard, and then you go from there.

Dr. Kim Bullock

Principles and guidelines, yeah, right, great. Well. The other thing I noticed is that you have put together the Mental Health Virtual Reality International Coalition. You founded that. Could you tell us a little bit about that? Because I was thinking about doing a society, and then, oh, my god. Jessica Stone's already done it!

Dr. Jessica Stone

It seems like we need to get together and put together. It really came out of my own sense of isolation and saying, "Hey, where are my people?" It's definitely three, it might even be four years ago, I put out a LinkedIn post and said, "Where are my people? I would love to get together." And I had a big response to that. I really wasn't expecting it. I thought it was just going to get buried, along with, you know, so many other things that we put out there, and people from all over the world were coming.

Dr. Kim Bullock

Yeah, there's very few forums that's focused on this topic, right?

Dr. Jessica Stone

There are people out there, and that's fantastic. And so, I've even, you know, been reaching out to others, saying, hey, why don't we join forces? The whole thing here is that the fragmentation really doesn't do any of us any good. We can write amazing things if we put our powers together. And so that was the whole reason, and it's just continued. We have a small but mighty group who we meet either every month or every other month, depending on what projects we have going on. We've written a white paper. We have a podcast that we've been recording episodes for close to a year now, but we just launched it last month. We wanted to have a stockpile of episodes to share, and I can't wait to listen. Yeah.

And then we also have just submitted to JMXR. If any isn't familiar with that journal, that's a great place. It's free access public assets, which is amazing. No pay walls to get through on that one. And we just submitted standards, as you were saying, standards and principles for use of XR in mental health treatment. And you know, that's an ongoing, fluid document. We're putting out there a place to start.

Dr. Kim Bullock

So where can people find that?

Dr. Jessica Stone

It's in the pipelines, you know, where we're at the tail end of it, and I'm not quite sure what episode it'll be in or not episode, but-

Jessica Hagen

It's the Journal of Medical Extended Reality, right?

Dr. Jessica Stone

It is, yes, I think they publish four times a year, so whichever publication it comes out, and I'm not quite sure.

Jessica Hagen

We'll link that on our site when it comes out.

Dr. Kim Bullock

Yeah, that would be wonderful. What do you think the biggest challenges you're finding in this field of mental health and technology are right now, or have been? I think I learned the most from people's kind of thorns, like what's challenging?

Dr. Jessica Stone

I think that that is quite multifaceted, but I'll try to boil it down to a couple key things. You know. One of them is access. It's the technology. How do you get the hardware and the software into the hands of people who would most benefit and all of that, there's the fragmentation in the industry itself of, we have all of these headsets and programs that only work on this one and not that one, and this one needs a subscription, and this one doesn't. And you know, if you're going to do all of those things as a clinician, you're going to spend a ton of money, and you're going to have many, many headsets, and know which one does what for whom, and all that kind of stuff. The less fragmentation we have in that, I think the better.

Even when you're presenting to say a hospital of saying this has value, it's like, okay, well, can it do this or that? Well, then you're going to need this other one. You know, nobody wants to deal with all of that. How do I use it? What's the lowest common denominator of the ease of access to this stuff. There's that in mental health in particular, I think a lot of other industries are well far ahead of where we are in the mental health field in terms of adoption. I wrote a book called "Technology and Mental Health," and it's like a focus book, so it's a shorter book, and really honing in on that topic. And in there I had a whole conversation, I suppose, with myself as I was writing it, to talk about not wanting to do any harm. That whole do no harm while doing good, even though, you know, we don't, as psychologists, take that oath, it still stands.

So I think there's a lot of concern that if I don't understand enough, and technology is something that a lot of people in the mental health world don't embrace us, even on a personal level, it's a different way of doing things. Then on top of it, you have, I have this client for whom I'm responsible, and I'm trying to do the very best treatment I can for them. If I'm not feeling very comfortable and confident in it, how can I possibly bring it into my treatment?

Dr. Kim Bullock

Yeah, the provider confidence and acceptability.

Dr. Jessica Stone

There's a book that I read that was a little over 100 years old, and I giggled aloud. I'm a book nerd, and I go very deep dive. I want to know where things came from, and I want to learn more about psychology, and I way back hundreds of years ago, like trying to trace all those things. And one of the things that I read, that I chuckled aloud, was it said psychology is slow to change, and this was over 100 years ago, and the things that they listed that they were slow to change about were the same things that I was sitting there writing about.

Well, you were right, and that is still very true today, and I think it is because we want to do the right thing, and I think that is valuable and valid. And it's also important to say, hey, even though this isn't maybe a traditional mechanism, the same traditional components, those foundations are what we're applying to these new technologies and these new ways of connecting with people and having people have experiences and not to discount that, I think is enormous.

Dr. Kim Bullock

Yeah, I hear what you're saying. So, clinicians as a group want to do the right thing, not harm people, but we also need to stretch our limits and be open to novelty and change and doing things differently. And sometimes those two are kind of contrary and hard to balance. Yeah, all right, so anything else you think you would like to share, or you're excited about, or anything?

Dr. Jessica Stone

Oh, primarily, I hope people continue to get involved. I hope clinicians and people who are experts in mental health that they will branch out, as you were just saying, and I hope that companies who are developing will also branch out. There'll be a lot more connection between those groups, more roles like what I had as the chief psychology officer - the acknowledgement of the importance of that. I think it benefits everybody, benefits the developer, the company, the end users. Like it's win, win. And other than that, please, if you're interested in this area, join us in MHVR and become more and more involved. Our four cornerstones are clinical, development, research and education. So, if you're interested in any of those areas that have to do with mental health.

Dr. Kim Bullock

Definitely interested in joining, if you’ll have me. Okay, thank you, Dr. Stone, for joining us. It's been such a pleasure and privilege.

Dr. Jessica Hagen

Yes, Dr. Stone, thank you so much for joining us.

Dr. Stone

It was great to be here. Thanks for having me.

Dr. Kim Bullock

All right, that's it for this episode of Psychiatry XR. We hope you gained a new perspective on the use of extended reality in healthcare, and thanks for listening.

This episode was brought to you by Psychiatry XR, the psychiatry podcast about immersive technology and mental health. For more information about our podcast, please visit the website, psychiatryxr.com and be sure to subscribe to the podcast and tune in again next month to hear from another guest about XR use in psychiatric care. You could join us monthly on Apple Podcast, Twitter, Spotify, or wherever you find your podcasts.

This episode of Psychiatry XR was produced by Kim Bullock and Jessica Hagen, and please note the podcast is distinct from my clinical teaching and research roles at Stanford University. The information provided is not medical advice and should not be considered or taken as replacement for medical advice. This episode was edited by David Bell and music and audio was produced by Austin Hagen. See you next time!