Dr Mark Wiederhold podcast transcript

This is the audio transcript of Coaching Through Chaos Podcast episode 01.

0:00 introduction

4:42 Mullen: I was so thrilled to have this interview with Dr Wiederhold, the Virtual Reality Medical Center  has been around for over 20 years. They started out treating general phobias, like fear of flying, or fear of public speaking, but over the past decade they ventured out into helping treat our wounded warriors with PTSD. They have a home base here in San Diego but they have locations also in Los Angeles,  China and Brussels. Their work with the wounded warriors is already approved in some of the VA hospitals across the country.
My interview there took on a life that I didn't event expect, I showed up for what I thought was going to be a twenty minute interview, and it turned into an almost 3 hour experience. I couldn't possibly fit all of the information that I got into this episode so you can find an article on my entire experience - along with some pictures - at PriceOfBusiness.com.
Just look for the CoachingThroughChaos podcast page.

5:47 Mullen: we're going to take a short break but when we come back, Dr Wiederhold will get  right into answering the question of what does  the Virtual Reality Medical Center do, and what the heck is virtual reality therapy ?

6:03 music interlude - - -

6:20 Mullen: thank you Dr Wiederhold for being here

6:22 Wiederhold:  my pleasure and thank you for your interest . We've been treating patients with Virtual Reality therapy for over 20 years. We first started treating patients with simple phobias - for example fear of flying, fear of driving and fear of public speaking. You may be interested to know that fear of public speaking  is the most serious phobia that people have, and studies have shown that people are more afraid of giving a speech than dying.

6:51 Mullen: yes, as a therapist I have heard that over time...

6:52 Wiederhold: and if you think about that, they are very serious disorders because if a person or an executive has a fear of flying or cant drive to their next meeting, or cant deliver a bored presentation, that can affect their job quite seriously.  so we've been able to develop virtual reality therapy, which is a 360 degree computer simulation which is a substitute for what we call exposure therapy in the real world.
7:19now the way this works there's really two main parts of it - the first part is exposing the patient usually in a head mounted display in which they're fully immersed or present in for example, a virtual airplane. Or they may be in front of a virtual podium in front of a virtual audience.   The second part is we record their physiological signals - for example their breathing rate, their heart rate, their skin temperature - with non invasive sensors, in real time.
7:51 and so what were able to do is  use a technique called Cognitive Behavioral Therapy - and this type of therapy which uses the exposure model by the way, has been recommended  by the National Institutes of Health as well as the Institute of Medicine.
So it's been used for well over 40 years...

8:11  Mullen: I've been using that myself, but I've been limited in that we don't have  360 degree exposure for our clients in the therapy room.

8:20 Wiederhold: and I'm glad you brought that up because  virtual reality is just a tool and it's not a substitute for good clinical skills. Having said that, there are many advantages of virtual reality therapy.
For example, in the old days , do you remember there was a time when you could actually walk your relatives to the ramp of the plane...

8:39  Mullen: absolutely, yes

8:40 Wiederhold: well, you can't really do that now - and so its almost impossible for a therapist to go with their patient to the airport. There's inconvenience, and the other main issue is that it could be embarrassing for the patient . And if we think about anxiety disorders, the biggest problem we have with patients who have anxiety or phobia, is they often are reluctant to come to therapy...
9:02 and the last thing they want to do is be in front of a large number of people and for example they might have an embarrassing episode on the plane, so one of the major advantages of Virtual Reality therapy is it can be done in the comfort and privacy of the therapist's office.

9:16 Mullen:  I've been treating people with phobias and trauma for years, I can only take them so far, and for people that don't know what those sessions look like, its a lot of imagination work. we can talk  to the client, get them visualizing in their mind, what the situation is that they're fearful of.  And I've treated a lot of people for fear of flying, however it can take several sessions to several months of sessions and lots of imagination homework in between where they're bringing up images of their fearful events.  So it sounds to me that the advantage would be that the person instead of us sitting there and imaging what its like, you're going to put glasses on them and bring up a scene and they're going to actually experience being in the plane.

10:04 Wiederhold: and that's exactly what we try and do, what we do is called suspension of disbelief - and the more immersed or present the patient is - meaning the more they feel they're on a real airplane the better they're going to do in therapy.
And I'm glad you mentioned some of the limitations of imaginal therapy,  although certainly, certain patients do very well with imaginal therapy. However the scientific literature shows that only about  15 percent of  people are good imaginers.
For the other group it's a little more difficult. The other nice thing about  virtual reality therapy is , as you mentioned before, avoidance is a major issue with patients with anxiety and phobias. with the virtual reality its pretty much in you face. you really cant get away from it and you really need to confront it.
10:54 and although that sounds confrontational it is very important for the patients to face their fears. now let me make what we consider an important distinction in our work here, in that we don't use the technique called flooding.
we think flooding is a little bit counter productive, and what we do, because were monitoring their physiological responses we can control what I call the dosage of reality exposure. so for certain patients we have to be  a little more gradual in our exposure response. however it needs to be compelling enough that they have a level of arousal. And this is really the key to exposure therapy - is having the appropriate level of arousal.  We want them to be engaged, we want their brain to do the work to overcome their fear, to build new network pathways. However, we don't want to cause a panic attack. Were very concerned about that - and because we use this gradual approach with the monitoring - and that's combined with building specific skill sets of cognitive therapy - our drop-off rate is less than 2 %.

12:02 Mullen: that's an amazing statistic. can you tell us a little bit about how you got into doing virtual reality therapy? To me it sounds like that's the way of the future but you've been this now for over 20 years . So tell us about how it has morphed over time, if you could.

12:21 Wiederhold: the original virtual reality equipment required supercomputers - 20 years ago a major breakthrough occurred with the development of advanced graphic card technology - whereby  the VR environment could be viewed on a desktop computer -  the processors were powerful enough, you could actually afford a computer  to do that .
Twenty years ago I was part of a group that started the medicine meets virtual reality program - which was primarily a group of surgeons that were using VR therapy for surgical planning and surgical imaging. One of the guests at the program  was JARON LANIER, who was one of the pioneers of Virtual Reality, and he actually talked about virtual kitchens... twenty years ago, people planned their new kitchens using VR.
13:08 And so, actually, Dr Brenda Wiederhold is the person who came up with the first idea to try  to use it as an adjunct for phobias. And it's one of these stories where you never really know how things turn out. Part of it was luck that we chose phobias because the ability  to use a virtual exposure for phobias turned out to be one of the most effective uses of the therapy.
Now in our clinic, our success rates can be over 90%, for example.
If you finish the program for fear of flying our results are greater than 90%.
What that means means though is it doesn't work for everybody. 
And were very clear about that  - it doesn't work for all patients, you have to come for all your sessions, you need to do the homework, and its a lot of work to do the therapy, it really is. The patient has to do a lot of work and the Virtual Reality Therapy process also requires some extra effort by the therapist.

14:07 Mullen: I was going to ask if you can explain what a session may look like, because I assume you're not just putting glasses on a person and turning on the stimulus, with the physiological monitors attached. I assume there is a therapist in the room. Can you talk about how the therapist would interact in a virtual reality session.

14:24 Wiederhold: sure, when the patient first comes they have a full and complete assessment  and during the first session  - which takes about an hour and a half to two hours - there is no VR.
That's the standard assessment and intake as all clinicians need to do.
In the second session the patient is introduced to the physiological monitoring and what we do is called a PHYSIOLOGICAL STRESS PROFILE. So we actually give them a stressor in this case a maths stressor - subtracting 7 from 100  - which gets most people pretty agitated

14:56 Mullen: I think I can feel my own anxiety getting raised just thinking about it

15:00 Wiederhold: exactly right - and so - we allow them to not only experience what stress is but to view it on the screen with the physiology.  And then we spend time teaching them to do abdominal breathing, progressive muscle relaxation, so we give them a set of skills that they can use to control their anxiety or arousal. This is very empowering for patients.  And when they then learn this skill and they're comfortable doing it, we then will  proceed with the first Virtual Reality session.

15:30 Mullen: So it's a gradual building of skills and then the exposure comes - just for people who are listening who are thinking gosh what would that look like .  So that's  been really helpful to hear what would happen.
I think it's a good time to take a little break - and we'll come back and you can tell us how the virtual reality therapy is being used to treat our wounded warriors.

15:52 interlude

16:19 Mullen: we're back with Dr Wiederhold of the Virtual Reality Medical Center in San Diego, and we're going to now move into the segment that we're really here about - how the  Virtual Reality Medical Center has turned the work that they've done for years with phobias into treating our combat veterans.

16:37 Wiederhold:  thank you so much.   In the course of treating the phobias, we also started treating Post Traumatic Stress Disorder in people that had suffered serious motor vehicle accidents - and we've treated probably 100 patients who have PTSD for MVA, and that really was one of the links that allowed us to look at the possibility of using the tool for treating PTSD in our veterans. Now there's a main difference between simple phobias and PTSD  - PTSD  is a much more complex disorder, there are multiple problems, for example,  we have a lot of co-morbid conditions  - in one of the studies that we did half of the veterans also met the criteria for traumatic brain injury as well as PTSD

17:23 Mullen: right, which is another very serious co-occurrence, as you mentioned.

17:27 Wiederhold: other issues have to do with suicide, substance abuse, family disorder,  family violence - it is serious business taking care of people with trauma . The way we started this - we had funding from the Office of Naval Research to do a study at the Naval Medical Center in San Diego . That study allowed us to transition our technology and develop virtual reality exposure therapy for our veterans. We also used the physiological monitoring. We did several studies at the Navy and found overall, using the Virtual Reality Exposure Therapy with monitoring of physiology, we had about 80% overall success rate.

18:10 Mullen: that's again another tremendous statistic

18:13 Wiederhold: in addition ,we found a very low dropout rate - what really made me most excited about this therapy is that a lot of the younger members and younger veterans - because they go through a lot of computer type training - and some of them do play video games -  now let me be clear : virtual reality therapy is not a video game, its  not meant to be a video game. However, this population of patients has a lot  of familiarity with the techniques and the tools  and a lot of them found it   frankly enjoyable, they found it easy to transition.
and what we learned, we stopped calling this a therapy session  -
18:55 we actually called it re-training.  because one of  the problems with helping people seek treatment is avoiding the stigma. and so we would just say - why don't you come on and you can do another hop .

19:07 Mullen: and what's a hop ?

19:09 Wiederhold: a hop is essentially going out on a mission - and so we had retired military and active duty  military that were treating the patients - they were able to establish a critical rapport with them and  a level of trust - and that's so important as you know . But they were able to effectively use the tool to expose them to the issues and the cues that are causing the PTSD, causing their nightmares, causing their anxiety and allowed a lot of them to overcome. 
19:40 Now the results of the study, in terms of how do you know its working - well of all the patients that completed the program, with 80% success, we had all of them either return to active duty stations, return to full time employment or they're able to go back and be in school full time and perform well.

20:00  Mullen: fantastic, so you've got these people who were dealing with some really severe traumatic symptoms now getting back into their normal life, or re-entering life in a normal way  where they were otherwise feeling that they could not do that

20:14 Wiederhold: exactly. And as I said before, it doesn't work for everyone, we have to be very clear. In addition , some of the people that we treated they'd tell us - and we'll be the first to admit it - they still have some anxiety and they still have some discomfort, however its not at the level where it  interferes with their ability to enjoy their life or enjoy their family

20:35 Mullen: and that's one of the key ways of knowing you've treated someone successfully - is that their symptoms, although they may not be totally gone, or totally gone forever - the quality of the life that they're living is vastly improved.

20:48 Wiederhold: exactly correct. and that was really one of our end points. now were continuing to do additional studies using virtual reality - and were also fore example we were able to deploy several of our virtual reality systems to Iraq and Afghanistan. and one of the active duty navy  physicians took one of our systems to Fallujah and he was able to treat a number of patients in theater

21:11 Mullen:  I actually didn't know that part of it when I did my research on your clinic.  I know as a clinician the earlier you can treat a trauma the better the response to treatment.
and i also want to point out something you mentioned about the drop out rate - one of the biggest issues of getting our combat veterans help has been a concern about difficulty in joining and retaining them in therapy - so you've got this mode of treatment that seems to have a really strong hold on retaining them and helping them for the long term

21:43 Wiederhold: exactly.  The results of the small study for treating in theater were 86% success, so it was higher than our normal rate.
Now the reason this is important is it also allows us to look at some next steps - and one of the things we've been doing for  a number of years is called STRESS INOCULATION TRAINING  where  we actually take some of these skills that are similar - but they're not exactly the same - to treating PTSD and we allow the patients to be exposed to stressful stimuli before deployment  - and that's called stress inoculation training. We've been doing that for 10 years

22:27 Mullen: OK ... so getting them ready for what they might experience ...

22:30 Wiederhold: exactly - our hope really is to be able to prevent PTSD or possibly mitigate the serious types of effects that we're seeing.

22:40 Mullen: wouldn't that be amazing to do ... can you tell us a little bit about, or is there a particular success story you can tell us about? Everything you're presenting gives us such hope, or at least its speaking of hope to me, for this population.  Can you tell us a little bit or give an example of one of  your clients; talk about the symptoms they might have had when they came in and presented for the treatment  - and what their quality of life looked like at the end of treatment.

23:06 Wiederhold: yes, typically with patients - one of the biggest problems they have is with sleep disorders - they have invasive nightmares. They have difficulty being in crowded situations, for example a lot of times going to the mall or a crowded street scene - they're not able to do that.  And often they report panic attacks, anxiety, again I'll mention substance abuse and  those types of issues.
After the therapy, they learn the skills to control their breathing, to control  their heart rate, to control their muscle tension - and it helps them to relax. It also helps them to realise that they're not in Iraq anymore - they're back in the US. And they  can then use these skills to effectively mitigate  the effects of the stress of PTSD.
23:52 I remember a particular case of a young man who was a navy corpsman and he had particular problems with images that he encountered.   PTSD in medical corps
is actually much more serious than PTSD in our standard population. The reason is that medical personnel in addition to treating severely injured wounded members , they're also  exposed to the stress of warfare. For example, the Army medics, they're taught to shoot back first - as the first thing they do when they go to treat the wounded - so they're really getting it from both sides. Their level of PTSD is higher than the general military population.
But we were able to reduce the levels of nightmares and the intrusive thoughts that the person was having.
24:38 It is important to realize though that this person also told us that he still does have some problems. So he's not completely over it, but the key is that he is able to live a normal life. He's able to enjoy his family members, he's able to work and to be a productive member.

24:55 Mullen: fantastic - so , I still have so much I want to ask you, but I think we're going to have to keep it a little bit short - so I assume that  the people can come back if they need to, if their symptoms resurface, you can do some extra treatment . I'm getting a nod and an endorsement of yes, they can ...
Can you tell us where the treatment protocols are moving to, are you expanding the population that you  can treat as far  as  wounded warriors go - can  you tell us a little bit about that ?

25:21  Wiederhold: yes, we are. We've just opened up  another office in Coronado, here  in California . What we're trying do now  is migrate our therapy sessions to involve more treatment in the home and in the community. And we're able to do that now because a lot of the virtual reality hardware is being priced much more competitively - to the point where we can actually give the patient  a virtual reality set they can use in the home.

25:46 Mullen: so they can do their homework with the actual equipment at home

25:49 Wiederhold:  exactly. Which should be much more effective.

25:52 Mullen: Can our wounded warriors get that treatment funded from their VA benefits, or do they have to pay for this themselves?

26:01 Wiederhold: a number of Veterans Hospitals do have the virtual reality equipment, it's not available at all the VA hospitals but a lot of them do have it.

26:10 Mullen: fantastic. is there anything else that you would like us to know before we wrap up our interview ?

26:14 Wiederhold: I'd like to say a word of thanks to our patients, one of the reasons our success rates are so high is because our patients tell us what works and what doesn't work.
and were grateful. And I'm inspired that people who have had such horrendous experiences are still able to think about helping others. It is the most rewarding thing I've ever done.

26:35 Mullen: so you get rewarded and inspired every day with the patients that you're treating and I'm sure that you learn a lot from them as they're learning from you.

26:44 Wiederhold: exactly

26:45 Mullen: well I know I've learned a lot from you today and I want to thank you for your dedication to this population, and I want  to thank you for giving me this interview

26:56 music interlude - - -

27:13 Mullen: exit statements

30:00 end