Luke Robert Mason: You’re lis­ten­ing to the Futures Podcast with me, Luke Robert Mason.

On this episode, I speak with vir­tu­al real­i­ty ther­a­pist Michael Carthy.

The whole point of the ther­a­py is to build them up in to a moment where they have this sense of belief and you’re hop­ing that they will then leave the ther­a­py room and find a sense of effi­ca­cy that I can do this now.
Michael Carthy, excerpt from interview

Michael shared his insight into how he uses vir­tu­al real­i­ty to help indi­vid­u­als over­come anx­i­ety, con­quer their pho­bias, and tack­le their fears. This episode was record­ed on loca­tion in England, at London’s first vir­tu­al real­i­ty expo­sure ther­a­py clin­ic. It’s time to bury the 20^th cen­tu­ry and begin work on the 21^st. So, let’s begin.

Luke Robert Mason: Michael, could you explain what VR ther­a­py is?

Michael Carthy: The rea­son why I’ve set this kind of clin­ic up is real­ly because I’m fas­ci­nat­ed by the appli­ca­tion of psy­chol­o­gy. You know, not nec­es­sar­i­ly fig­ur­ing out why are peo­ple expe­ri­enc­ing what they’re expe­ri­enc­ing… You know, why am I expe­ri­enc­ing fears or pho­bias or anx­i­ety in my day? But I’m real­ly inter­est­ed in the how of change.

Traditional psy­chol­o­gy and coun­sel­ing will help peo­ple under­stand in a very lin­ear way why they are the way they are. Whereas what I’m real­ly focused on and what I’ve been spe­cial­iz­ing in for the last num­ber of years is the how. And for me, vir­tu­al real­i­ty ther­a­py is the how of change.

Mason: Now, you’ve gone through a num­ber of dif­fer­ent types of ther­a­py before you got to vir­tu­al real­i­ty ther­a­py. I know you were work­ing with hyp­no­sis at one point? I just won­der what is the sto­ry behind your work?

Carthy: My sto­ry starts like every­one else’s, I sup­pose. At the aged of twenty-five expe­ri­enc­ing… You know, you would­n’t say depres­sion but maybe just a moment where I was… I’d clas­si­fy it as prob­a­bly a quarter-life cri­sis. Working in a pro­fes­sion­al was­n’t ful­ly ful­fill­ing me. I was­n’t prob­a­bly get­ting what I need­ed in my rela­tion­ships, whether that was at home or with my friends or with part­ners, etc. And I spent about six to nine months just reassess­ing, try­ing to fig­ure out how can I make myself bet­ter, how can I get more of what I want? 

And when I turned to—and this is in Ireland at the time—when I turned to the tra­di­tion­al ser­vices avail­able, whether it was my GP—going to the doc­tor who tried to pre­scribe med­ica­tions that were sup­posed to make me feel bet­ter, or whether it was going to the local church and get­ting some coun­sel­ing, and that was just me sit­ting there for an hour just kind of feel­ing worse as I walked out than feel­ing what I expect­ed to feel, which was better. 

Or else going to psy­chi­a­trists, who again just looked at me in terms of my symp­toms and what I was pre­sent­ing with and want­ed to pre­scribe me more med­ica­tion, you know. In that moment, I start­ed to look else­where into the world of psy­chol­o­gy and real­ly into the appli­ca­tion of psy­chol­o­gy. And that’s where I start­ed to find things like cog­ni­tive behav­ioral ther­a­py. The fact that I can change my think­ing. And if I change my think­ing that will change how I feel. And that will change ulti­mate­ly how I act and behave. 

I start­ed to get inter­est­ed in hyp­no­sis as a real­ly kind of rapid way to work with some of the emo­tion­al bar­ri­ers and emo­tion­al blocks that were there with­in myself first, again to be able to change how I feel about myself and ulti­mate­ly to trans­late that into my real world. 

So that’s when I start to get inter­est­ed in I sup­pose rapid change and also in the appli­ca­tion of psy­chol­o­gy. So that’s where the hyp­no­sis and cog­ni­tive psy­chol­o­gy comes in. And then lat­er on I start­ed to get inter­est­ed in human givens, which Joe Griffin and Ivan Tyrrell, the founders of this process of change which real­ly did cre­ate a method­ol­o­gy or an approach that is very quick com­pared to what you get in the NHS here with twelve ses­sions of CBT if you present with some debil­i­tat­ing dis­or­der. They found that in three or four ses­sions, using the human givens approach, they can get peo­ple into a sim­i­lar sit­u­a­tion where they’re com­plete­ly free of what they were experiencing.

So these approach­es for me, what excites me is that they’re counter to this idea or this view that change is hard. That we have to strug­gle through two years of psy­cho­an­a­lyt­i­cal work in order to kind of have some epiphany that’s going to make me feel bet­ter. And they’re counter to the idea that I need some med­ica­tion, I need some­thing that’s been cre­at­ed by the phar­ma­ceu­ti­cal indus­try in order to make me feel hap­py about myself.

So we have the cog­ni­tive psy­chol­o­gy (CBT). We have hyp­nother­a­py, which is extreme­ly effec­tive in my expe­ri­ence and with my clients. We have human givens approach, which I real­ly real­ly enjoy read­ing about and learn­ing more about. And the final one is the pos­i­tive psy­chol­o­gy, which has become of inter­est for me in the last five or six years. I’m recent­ly doing a mas­ters in pos­i­tive psy­chol­o­gy, and again it’s in the appli­ca­tion of the prin­ci­ples and the tools that have come out of the pos­i­tive psy­chol­o­gy space that I’m real­ly inter­est­ed in.

Mason: So are you find­ing crossover between some of the work that you were doing pre­vi­ous­ly to VR ther­a­py? Is VR a form of enhance­ment of pre-existing ther­a­pies, or is it an entire­ly new form of therapy?

Carthy: You could com­pare it to things like sys­tem­at­ic desen­si­ti­za­tion of fear. You could com­pare to flood­ing expo­sure, which was devel­oped in the kind of 60s and 70s. But real­ly for me I think it’s a new, com­plete­ly new form of of treat­ment, which has been extreme­ly lack­ing in the ther­a­py room. Something where I can sit with my client in the com­fort of my office here in London, or if I’m in Dublin, and I can grad­u­al­ly and slow­ly, using my expe­ri­ence and all the ses­sion time that I’ve had to kind of judge how quick­ly and how fast to take these peo­ple into the sit­u­a­tion that they’ve been try­ing to avoid for such a long time.

And for me it’s real­ly been a miss­ing piece in terms of the arse­nal or the set of tools that I can turn to when I’m sit­ting in a client ses­sion. You know, before, over the last kin­da ten years with­out the VRT, help­ing peo­ple to over­come their fears and their pho­bias, there would be this moment after ses­sion two or three or four where I would be tak­ing them, phys­i­cal­ly, into the Tube for the first time or maybe tak­ing them to the top of a tall build­ing here in London—the Heron Tower’s around the cor­ner with the nano ele­va­tor that goes from 0 to 40 floors in six­ty sec­onds or what­ev­er. And real­ly I was hand-holding through that process. You know, the whole point of the ther­a­py is to build them up into a moment where they have this sense of belief and you’re hop­ing that they will then leave the ther­a­py room and find a sense of effi­ca­cy that I can do this now.

And some­times it’s that one moment where they’re stand­ing at the top of the Heron Tower look­ing out over London, some­thing they haven’t done in ten years. Or they’re in that tube and they’re there sit­ting there feel­ing com­fort­able as the train moves away from the plat­form. Sometimes it’s that one moment that allows them to find that sense of, ​“Well, I can maybe do this now. Maybe this idea is in my past.”

Mason: So could you take us through what an aver­age VR ther­a­py ses­sion looks and feels like? So what is the process behind a VR ther­a­py session?

Carthy: Yeah, there’s much more to it than just the VR sys­tem, just the tech­nol­o­gy, just the head­set, and just the immer­sion. Beforehand I’m very very care­ful to meet the per­son, get to know them, to under­stand their expe­ri­ence of fear or this pho­bic reac­tion, or what we would call the fight-or-flight response. Even though there are huge com­mon­al­i­ties across every­body who expe­ri­ences fear and it’s one of those uni­ver­sal emo­tions that we all expe­ri­ence prob­a­bly almost every day—fear, wor­ry, concern—there is indi­vid­ual kind of trig­gers or indi­vid­ual trau­mas or indi­vid­ual expe­ri­ences that that per­son has had.

So it’s real­ly about gath­er­ing the infor­ma­tion ini­tial­ly, get­ting to under­stand it from their per­spec­tive, build­ing a sense of trust and rap­port with the client, going to some scales and real­ly kind of ana­lyz­ing exact­ly where they’re at in their expe­ri­ence. And then it’s about decid­ing what form of treat­ment they need. Whether it is some cog­ni­tive ther­a­py. Whether it’s a bit of pos­i­tive psy­chol­o­gy, maybe the inter­ven­tions from that space. Whether we use some guid­ed visu­al­iza­tion tech­niques to even first of all, just in their imag­i­na­tion, imag­ine over­com­ing the fear.

And then even­tu­al­ly the VRT comes in. It’s a step­ping stone between the ther­a­py room and the real world. You’re hop­ing that in the immer­sion of this vir­tu­al expe­ri­ence which feels extreme­ly real, that they start to get this idea that maybe this can work for me. Maybe I can now leave the office and walk out and face my fear.

Mason: I think there is a degree of mis­com­mu­ni­ca­tion when it comes to vir­tu­al real­i­ty ther­a­py. People just assume that you come into your office, Michael. You sit down, you put the VR head­set on, and sud­den­ly you’re cured. But it feels like the key aspect to make the tech­nol­o­gy work is this kind of feed­back process where it’s not just the tech­nol­o­gy itself but it’s the fact that the tech­nol­o­gy is assist­ed by some­one like your­self with cog­ni­tive psy­chol­o­gy train­ing. Could you talk to the impor­tance of this thing around being assist­ed? The fact you need some­one to guide you through it.

Carthy: Yeah, you’re com­plete­ly right. I mean, I would com­plete­ly agree with you in say­ing that. The VR ther­a­py, the technology—and it is at a posi­tion where it’s extreme­ly use­ful as a tool—is actually—I would con­sid­er to be dan­ger­ous on its own, ie. if some­one was just to come in and start play­ing around the soft­ware with­out hav­ing that trust­ed and expe­ri­enced ther­a­pist or prac­ti­tion­er with them, they could prob­a­bly do more dam­age than good. 

The rea­son is that it’s about being able to judge the sit­u­a­tion, to rec­og­nize how far to take the per­son into the expo­sure. There’s the rare occa­sion where you flood some­one with with an expo­sure, ie. they have a fear of spi­ders and you have four taran­tu­las walk­ing around their vir­tu­al arm and that’s a flood­ing expe­ri­ence. Maybe some­times that can help the per­son get over, but it would­n’t be an enjoy­able experience.

So the core of this is actu­al­ly the self-determination the­o­ry, and that’s what a good prac­ti­tion­er will do, will be to give the per­son a sense of auton­o­my over the process. Which means that they’re in con­trol of it. As I’m explain­ing it to peo­ple I’m explain­ing to them that you’re in con­trol of every­thing. I’m going to be com­mu­ni­cat­ing with you through­out the whole process, and through the repeat­ed expo­sures. And at any moment you can take the head­set off. At any moment you can just decide not to walk into the Tube. You can decide to close your eyes, even, in the vir­tu­al world as well. So real­ly they’re in con­trol of that process, which gives them a sense of auton­o­my over the situation.

The sec­ond part of the self-determination the­o­ry is a sense of com­pe­tence or mas­tery. So it’s a grad­ual mas­tery over their fear, the thing they’ve been avoid­ing. Because some­times it’s maybe for twen­ty years, twenty-five years of their life they’ve been avoid­ing it. So it’s a grad­ual sense of mas­tery. It’s not this quick win, this quick moment, even though I would say the whole process is quite rapid com­par­a­tive­ly to oth­er treat­ments that are out there. But it’s about a grad­ual sense of mas­tery over the situation.

And then the last com­po­nent of the self-determination the­o­ry is a sense of belong­ing. And I think that comes from a sense of feel­ing proud. What would their par­ents say? What would their fam­i­ly say when they see them kind of final­ly get­ting in that car and hit­ting the motor­way, or you know stand­ing up and doing a pub­lic speak­ing event which would have been debil­i­tat­ing for them a cou­ple of weeks before? So the sense of belong­ing comes from how will peo­ple see them, how will they see themselves. 

So I think a good prac­ti­tion­er is think­ing about all of these ideas, think­ing about these well-established the­o­ries, and is tak­ing peo­ple at a pace that’s not dan­ger­ous, that’s not going to cause dam­age. And it’s done in a real­ly safe and con­trolled way. And I think that’s the skill in work­ing with some­one as a VRT ther­a­pist or what­ev­er you want to call it.

Mason: So one of the things about ther­a­py is it needs to be hyper-customized to the indi­vid­ual or the patient you’re deal­ing with. And one of the things around VR is that you can hyper-customize these envi­ron­ments, at least as far as I under­stand it. Could you talk a lit­tle bit about the soft­ware you’re using to gen­er­ate the expe­ri­ences for the indi­vid­ual you’re work­ing with?

Carthy: Yeah, I think that is actu­al­ly the beau­ty of the appli­ca­tion, the back­end, the soft­ware. Psious is actu­al­ly the name of the com­pa­ny who devel­op these envi­ron­ments. There are thirty-plus envi­ron­ments that you can use for a spec­trum of dif­fer­ent fears and pho­bias that peo­ple might face. The most com­mon ones being fear of heights, fear of dri­ving, fear of the Tube for trans­port, fear of pub­lic speak­ing, these kind of ones are the most com­mon. Fear of fly­ing would be anoth­er one that’s real­ly common.

Mason: And what do some of those look like? What’s the expe­ri­ence of being in one of those examples?

Carthy: Well the best way to describe it would be to say it’s like being in a cin­e­ma. Imagine if we were sit­ting in West London right now, maybe sit­ting in Leicester Square in one of those big cin­e­mas. It’s an immer­sive expe­ri­ence, you know. You’re sit­ting there watch­ing a hero movie. Or you’re sit­ting there watch­ing a sad movie, maybe you cry. You’re split­ting a hor­ror movie, you feel afraid. You know just by sit­ting in a cin­e­ma screen and by observ­ing what’s hap­pen­ing on the screen and the kind of sen­so­ry expe­ri­ence of the sound and the whole sit­u­a­tion, it can trig­ger a very real response inside the body and inside the mind. 

For exam­ple if I’m watch­ing a hor­ror movie, there’s a part of me that cog­ni­tive­ly, intel­lec­tu­al­ly, knows that I’m sit­ting in a cin­e­ma screen. I’ve been here one hun­dred times, it’s the mid­dle of the day. But there’s anoth­er part of me, the emo­tion­al part (you can use any metaphor you want to describe it, whether it’s the uncon­scious mind or just the emo­tion­al part who we are) that will trig­ger very real feel­ings. Because that part of me can­not real­ly tell the dif­fer­ence between what’s real and what’s fake, what’s fan­ta­sy or what’s real­i­ty. As it watch­es the cin­e­ma screen it just can’t tell the dif­fer­ence. So what does it do if there’s some­one being killed or it’s a scary moment? There’s a part of me that’s kind of push­ing the fight-or-flight response. The sur­vival instinct kicks in. Adrenaline, heart rate, increas­es. Body tem­per­a­ture increas­es. And it feels so real even though cog­ni­tive­ly, intel­lec­tu­al­ly, I know I’m com­plete­ly safe.

This is the exact same when it comes to a pho­bic reac­tion. A lot of peo­ple feel sil­ly, or they feel ashamed, or they feel like, ​“Why do I have this thing? I know I’m com­plete­ly safe.” But there’s a part of me that’s gen­er­at­ing this sur­vival instinct, this fight-or-flight response.

So rec­og­niz­ing that that’s what it’s like in a cin­e­ma screen, VR is prob­a­bly one step fur­ther. It’s a ful­ly immer­sive expe­ri­ence, where now you’re kind of the star in the show. You’re not sit­ting there watch­ing a screen, you’re in the screen. So now you’re in the hor­ror movie. Now you’re stand­ing there, and if it’s some­thing you’ve been run­ning away from for a long time…well, you feel like you’re the star of the show. 

So it’s this ful­ly immer­sive expe­ri­ence where you’re in con­trol, and I would say that it works with that part of the mind where there’s no log­ic. The part of the mind that con­trols the fight-or-flight response in the exact same way. So when peo­ple are sit­ting here in my office here in London or in Dublin, I sit them down and they’re hav­ing very real-world respons­es as they’re immersed inside the vir­tu­al real­i­ty envi­ron­ment. And that’s amaz­ing, because what it allows me to do is in real time, work with that per­son through the emo­tion. And the ulti­mate goal is to allow peo­ple to rec­og­nize the imper­ma­nent nature of emo­tion. That even some­thing like fear or the fight-or-flight response will of course come, but if we start work­ing with it instead of run­ning away from it, it goes quite quick­ly. Very imper­ma­nent; they can come and go quite fast.

What most peo­ple are doing when they are expe­ri­enc­ing high emo­tion­al arousal like fear is they’re try­ing to con­trol every­thing, almost. If they’re on an air­plane, they’re think­ing you know…they’re try­ing to lis­ten for nois­es in the engine. They’re try­ing to see if the stew­ardess knows what she’s doing. They’re lis­ten­ing and hop­ing that there won’t be bombs or tur­bu­lence because they think if they’re guard, if they’re pro­tect­ed, if they take care of them­selves, they can do some­thing about it. Which of course is not true. So their locus of con­trol is real­ly external—it’s real­ly outside.

So in the ther­a­py room here, what we do is we immerse them into those expe­ri­ences like being on an air­plane where there’s tur­bu­lence. But what I’m doing with the client is I’m get­ting them to focus on what they actu­al­ly can con­trol. And there’s only a few very finite things that we can con­trol in this world, you know. I can con­trol my breath­ing. I can always con­trol my breath­ing. I can con­trol things like my body pos­ture. If I’m speak­ing I can con­trol the pace at which I speak, which is very rel­e­vant for some­thing like pub­lic speak­ing, for exam­ple. I can con­trol whether I’m smil­ing or not, or what I’m doing with my face. 

The rea­son why these things are real­ly pow­er­ful is actu­al­ly because it cre­ates a feed­back loop. What I do phys­i­cal­ly with my body in terms of my body lan­guage, my smile, my breath, will actu­al­ly calm the body and calm the cen­tral ner­vous sys­tem, the parasym­pa­thet­ic and the sym­pa­thet­ic ner­vous sys­tem that goes com­plete­ly out of whack. By focus­ing on what I can actu­al­ly be in con­trol of, it can bring peo­ple through that emo­tion quite quick­ly. And they expe­ri­ence high emo­tion­al arousal, it comes, it goes, and as the wave wash­es over them they’re still stand­ing there and they’re still in the expe­ri­ence rec­og­niz­ing that, ​“I sur­vived it. I coped through it this time.” Instead of hav­ing that real­ly debil­i­tat­ing moment of, ​“I can’t do it. I’m not going to board the plane. It’s time for me to go home.” Or else they cre­ate a pletho­ra of cop­ing strate­gies or drink­ing alco­hol or maybe tak­ing some Valium or what­ev­er it might be. All of these things are just kind of help­ing get through the moment, but in a way where they believe they still can’t do it.

So peo­ple are leav­ing this expe­ri­ence focus­ing on what they can con­trol, find­ing evi­dence to sup­port the fact that they can do it, which builds a sense of self-belief and self-efficacy. And it trans­lates into the real world. I some­times describe vir­tu­al real­i­ty as a step­ping stone between the ther­a­py room and the real world. And for me that’s exact­ly what I’ve seen, using it now for about a year with hun­dreds of clients, hun­dreds of ses­sions with peo­ple. And I would­n’t say it’s a stand-alone treat­ment, it’s a catch-all and it’s a sil­ver bul­let or any­thing like that. But I would say in con­junc­tion with every­thing else that I’ve been spe­cial­iz­ing in for the last ten years, it’s become extreme­ly effec­tive and some­thing I’m using every day.

Mason: So let’s talk about some of that con­trol. So are you able to con­trol the envi­ron­ments through the soft­ware? Are you able to make them more intense or less intense, depend­ing on the indi­vid­ual you’re work­ing with?

Carthy: Yeah, exact­ly. To answer your orig­i­nal ques­tion, I would say yeah, of course. That’s why it’s so good. Because being able to tailor-make an approach for the client is real­ly impor­tant. Everyone comes with their own kin­da spe­cif­ic sit­u­a­tions that we have to change. So the back­end, the Psious soft­ware, pro­vides a back­end that is com­plete­ly customizable. 

Let me give you an exam­ple. So we’ve been talk­ing about fear of fly­ing. Someone could have a trig­ger that says they have a fear the night before the flight, for exam­ple. Or it’s the antic­i­pa­tion at the board­ing gate. Or else it’s none of that, it’s actu­al­ly when they sit down on the plane and the doors close. Or it could be it’s only when I’m at the win­dow. Or it could be it’s when I’m on the aisle. Or it could be when I’m at the front of the plane of the back of the plane. It could be it’s only when it’s rain­ing, or it’s only at night­time. Sometimes the trig­ger that cre­ates the pho­bic reac­tion is so spe­cif­ic. Because real­ly it ties all the way back into a moment that they’ve had in the past, what we call the ini­tial sen­si­tiz­ing event, some trau­mat­ic situation. 

So what it allows me to do is to cap­ture infor­ma­tion from the per­son, get to know them and their expe­ri­ence, and then I can real­ly custom-make the expe­ri­ence for them. What I mean by that is if it was at night­time in the rain and they were sit­ting at the win­dow at the front of the plane, I might­n’t give them the expe­ri­ence straight away. I might build up to the one moment. But I could take them on the plane, maybe sit them on the aisle, it’s the mid­dle of the day, there’s no tur­bu­lence. And that could be their first expe­ri­ence of get­ting on a plane. And then even­tu­al­ly we’d build up to this trig­ger­ing moment which they’ve been afraid of or run­ning away from for a long time. So that cus­tomiza­tion of the soft­ware and the tech­nol­o­gy is real­ly real­ly important.

Mason: Does the VR expe­ri­ence lose effi­ca­cy over time? Are you find­ing that ini­tial­ly it’s a very vis­cer­al expe­ri­ence because it’s so new, and then even­tu­al­ly the effect kind of wears off because they’re begin­ning to real­ize it’s a vir­tu­al envi­ron­ment? Or does it con­tin­ue to have the same effi­ca­cy through­out the peri­od of time that you work with the individual?

Carthy: That’s a real­ly good ques­tion. I actu­al­ly believe that there has to be some more research into that exact idea. What I can tell you from my expe­ri­ence using it, and what I can tell you from see­ing it with clients, is that def­i­nite­ly there’s a change in the clien­t’s anx­i­ety lev­el over repeat expo­sures. And I can see that when they’re leav­ing after ses­sion three or ses­sion four that if I com­pare (and we get a report and I can show the client this as well, which becomes a mas­sive con­vin­cer for that per­son), they can say, ​“When I walked oh wow, look at my anx­i­ety lev­el was doing this. Just before I board­ed the plane I could see how it increased. But now actu­al­ly when I go through the expe­ri­ence, it’s nor­mal.” And that becomes a strong con­vin­cer for the client to go out into the real world and prove that that’s true in the real world, too.

So I can tell you that there is a shift across the report­ing and over the repeat expo­sures. Whether that’s down to the fact that it’s los­ing effi­ca­cy as a tech­nol­o­gy and maybe they’re just get­ting used to the envi­ron­ment I don’t know. Or is it due to the fact that maybe they’re gain­ing a sense of self-belief and they’re boost­ing that idea of effi­ca­cy that maybe I can do this now. 

I want to believe that it’s the lat­ter. I want to believe that it’s not that they’re just get­ting used to the envi­ron­ment and it’s becom­ing eas­i­er. And my instinct, and obvi­ous­ly more research could be done around this, but my instinct and my gut feel­ing is telling me, because peo­ple do report back to me after they even­tu­al­ly get on that plane to Berlin or they get on that plane to Dubai or what­ev­er it is that it is, that it is trans­lat­ing into their real expe­ri­ence, too.

So what­ev­er’s hap­pen­ing in the ther­a­py room over a num­ber of ses­sions seems to be trans­lat­ing into their real world. Which might be evi­dence to sup­port the fact that it is just due to the fact that they’re chang­ing and the tech­nol­o­gy is stay­ing sta­t­ic in terms of how effec­tive it is.

Mason: Let’s talk about the fact that some of this tech­nol­o­gy is to a degree sta­t­ic. I mean is there things as a ther­a­pist you’d love to be able to work with or add on to the VR tech­nol­o­gy? For exam­ple smells or oth­er sens­es. You know, the smell of the fuel going into an air­plane, things like that. Is that some­thing that you want to see progress into VR ther­a­py eventually?

Carthy: Well we know that move­ment and the olfac­to­ry sens­es are some­times some of his strongest trig­gers for peo­ple in terms of bring­ing them back to emo­tion­al mem­o­ries. And that’s what this is. It’s about allow­ing some­one to be immersed into expe­ri­ence; maybe they see it, maybe they hear it, maybe they feel it in some way. And if you can add more sen­so­ry inputs into that, it’s going to I sup­pose be a ful­ly more immer­sive expe­ri­ence for that per­son. I can’t real­ly imag­ine how that would hap­pen apart from putting some­one inside like, a pod-like device where the smell’s being pumped in and there’s move­ment, I sup­pose. Because one of the lim­i­ta­tions I have noticed is when some­one is get­ting onto Tube or maybe they’re about to board a plane, they’re stand­ing here in my office and they’re walk­ing around you know, a four-foot by four-foot room. And so how they’re mov­ing or how they’re phys­i­cal­ly mov­ing does­n’t real­ly trans­late into the world in the same sense.

So I do see that adding some joy­sticks or adding some way for them to move a sit­u­a­tion would make it feel more real for the per­son, and maybe even boost that sense of auton­o­my over how in con­trol they are of the envi­ron­ment. Maybe that would make a big difference.

Mason: We’ve real­ized that to a degree there’s mas­sive effi­ca­cy with VR ther­a­py. But does that mean there’s cer­tain exclu­sion­ary cri­te­ria that you have to look at when putting some­one into it? If you know it’s going to have this mas­sive effect, could it also do the reverse?

Carthy: It’s some­thing that I have thought about a lot and have put a lot of safe­guards in place. So there are cer­tain cri­te­ria or cer­tain indi­vid­u­als that… Say for exam­ple peo­ple are tak­ing med­ica­tion, some­one’s tak­ing a beta block­er or tak­ing Valium or they’re on an anti­de­pres­sant or an antipsy­chot­ic. I mean, you could put them into the vir­tu­al expe­ri­ence after they’ve tak­en their dai­ly med­ica­tion and they won’t have a response, ie. the bio­med­ical sys­tem has been hijacked to a cer­tain degree and it would be you know, apart from them just enjoy­ing the expe­ri­ence, you’re not going to be able to get them to actu­al­ly face their fear in any real sense. 

So that’s one lim­i­ta­tion, peo­ple who are on dai­ly med­ica­tion. They might not be able to use the tech­nol­o­gy. And there might just be a process of help­ing them maybe get into a sit­u­a­tion where they don’t feel like they need the med­ica­tion and then even­tu­al­ly they can come and face their fear or their pho­bia or anxiety.

And the oth­er large con­sid­er­a­tion is to make sure peo­ple don’t leave with a neg­a­tive expe­ri­ence. It’s true to say, as I’ve already men­tioned, with­out a trust­ed prac­ti­tion­er and with­out some­one who kind of has all the expe­ri­ence that maybe I do or my busi­ness part­ner has, it could be very easy to give some­one more evi­dence to sup­port the fact that they can’t do it.

And we’re always very care­ful to take peo­ple as far as we can, even if it’s an inch, a step, some­times a mile because they’re able to do that. To a point where they can leave with a big smile on their face, they have a break­through moment, and that’s the whole…I sup­pose that’s the art to this, being able to watch some­one and just sub­jec­tive­ly judge… You know, when I see peo­ple I can see what’s hap­pen­ing even in their pulse in their neck, in their breath­ing, in their body pos­ture. You can kind of just gauge over a long peri­od of time where some­one is. And obvi­ous­ly you do have the bio­met­ric sen­sors that are cap­tur­ing the anx­i­ety lev­el in real time as well. So there is that kind of a del­i­cate bal­ance between tak­ing them just as much as they need to go but not too much so they have a neg­a­tive experience.

Mason: Could you run a ther­a­py ses­sion over the Web with some­one with a device at home, or do you still need to be in the same envi­ron­ment as that per­son to rec­og­nize those very sub­tle cues you were just talk­ing about?

Carthy: That’s a real­ly real­ly good ques­tion. So, I am fas­ci­nat­ed by tech­nol­o­gy prob­a­bly as much as I am by psycholo­gy. And this VRT is kind of where psy­chol­o­gy and tech­nol­o­gy meet for me. You see the mobile phone apps. You can see wear­ables these days. And you can see that what were kind of sep­a­rate domains are start­ing to kind of cross and we’re get­ting these won­der­ful appli­ca­tions. And a big step for­ward could be—and I know this is some­thing that com­pa­nies like Skype and there’s oth­er com­pa­nies out there who are try­ing to cre­ate this—is hav­ing vir­tu­al meet­ings with peo­ple where you’re sit­ting at home in your kitchen but every­one puts on their vir­tu­al head­set and now you’re sit­ting in a vir­tu­al board­room and some­one’s able to draw out what they’re going to do for today or come with a strat­e­gy for the day or what­ev­er it might be. And you can have these won­der­ful con­ver­sa­tions quite remote­ly but it feels like you’re there, and it feels like it’s real. And I can see a future where that’s pos­si­ble in this capac­i­ty where it’s a ther­a­pist and a client, some­one in need. 

And it would be par­tic­u­lar­ly use­ful for places like you know, I can think of the West of Ireland, for exam­ple. Or places like New Zealand or some very remote places where maybe access to high-quality expe­ri­ence ther­a­py is not avail­able. Or else maybe it’s too expen­sive. And if we could cre­ate these plat­forms where we could have these vir­tu­al set­tings where maybe I could judge some­one’s body lan­guage through the vir­tu­al expe­ri­ence. Maybe I could have an accu­rate read­ing like the bio­met­rics of anx­i­ety and maybe body pos­ture, maybe get a rep­re­sen­ta­tion of what the face looks like. And you would be able to safe­ly take peo­ple through the sit­u­a­tions but from two remote loca­tions. And I think that’s a very excit­ing idea, and I don’t know how far we are away from the exe­cu­tion of those ideas, but—

Mason: I mean, let’s take it one step fur­ther. We talk a lot about the obso­les­cence of cer­tain jobs through tech­nol­o­gy. Do you think your own job as a ther­a­pist is at risk from some AI that will be able to under­stand these sort of bio­met­ric trig­ger and then be able to deliv­er to the human auto­mat­i­cal­ly at home with their own device the exact sort of ther­a­py they need? Or do you think that’s a very dan­ger­ous pos­si­bil­i­ty, in actu­al fact, there’d still need to be a human-to-human ele­ment to make this stuff work?

Carthy: You know, because I’m so inter­est­ed in the tech­nol­o­gy sec­tor, I think it would be won­der­ful if there was an advanced enough AI to be able to pro­vide peo­ple with rel­e­vant and effec­tive and rapid appli­ca­tions of psy­chol­o­gy. I think that would be absolute­ly amazing. 

Would that mean that I would be out of a job? Probably not. I prob­a­bly would find a way to still be a part of that in some capac­i­ty. But real­ly you see this as kind of the democ­ra­ti­za­tion of psy­chol­o­gy through the method of tech­nol­o­gy. And I would wel­come it mas­sive­ly, and I think it would be—I think it’s real­ly required, in fact. 

You know, we only have to look at the sta­tis­tics com­ing from the World Health Organization about depres­sion in 2020, and we only have to look across the world at sui­cide rates, etc. to rec­og­nize that we are an ever-increasing dis­en­fran­chised pop­u­la­tion, our species. And any­where where tech­nol­o­gy can be applied to pro­vide peo­ple with an increased sense of iden­ti­ty, an increased sense of well-being, high emo­tion­al pos­i­tive emo­tions each day, make us health­i­er. I real­ly would wel­come that idea. Now, would it mean that I’d be out of a job? Not to sure. I’d prob­a­bly just go sit on a beach somewhere.

Mason: Or you could clone mul­ti­ple Michaels and have ver­sions of you in every­body’s head­set. The oth­er ques­tion that I have with regards to the work that you’re doing, what makes you specif­i­cal­ly inter­est­ing, and the work that you’re doing here in London inter­est­ing is the fact the you’re work­ing with these tools in the wild with indi­vid­u­als who need this sort of work and this sort of ther­a­py. And I won­der what sort of feed­back are you giv­ing to the peo­ple who make these plat­forms and make this soft­ware? Are you active­ly involved in that research process, and what are some of the things you’re ask­ing for and some of things that you’d like to see?

Carthy: Yeah. You know, the size of the com­pa­ny that I’ve been work­ing, they’ve been very very good in terms of pro­vid­ing infor­ma­tion for me to build a busi­ness around vir­tu­al real­i­ty. And we have been in con­tact quite fre­quent­ly and quite often in terms of giv­ing feed­back, and they have webi­na­rs and they have train­ing ses­sions all the time, etc. And I feel like they’re a lit­tle bit ahead of the curve in terms of, every time I kind of log in— I might go away for a week or work for week and can come back into the sys­tem, and there’ll be a new appli­ca­tion, there’ll be a new envi­ron­ment that they’ve created.

One of the lat­est ones is the EDMR or rapid eye move­ment tech­nique, which now you can do in the vir­tu­al world. It’s been used quite effec­tive­ly in France, for exam­ple, after the ter­ror­ist attacks, and it’s become this treat­ment or tech­nique that isn’t exact­ly about fac­ing fears and pho­bias but it’s about cur­ing anx­i­ety or trau­ma, post-traumatic stress—

Mason: Could you explain that a lit­tle bit more? So, how was it used after Paris? I’m not aware of this—

Carthy: Even out­side of the vir­tu­al world how it’s used is it’s about mov­ing the eyes back and forth while allow­ing your mind to wan­der back to a trau­mat­ic event. And what they find is—there’s still a lot of research to be done; it’s some­thing to do with short-term mem­o­ry and long-term mem­o­ry. But what they find is once you fol­low this exer­cise and you prac­tice it, kind of like you would prac­tice med­i­ta­tion, is that the emo­tion­al cur­ren­cy of the trau­mat­ic event starts to dis­ap­pear. And that’s how post-traumatic stress, or that’s how trau­mat­ic events can affect our expe­ri­ence. What hap­pens is we keep get­ting brought back to this emo­tion­al mem­o­ry and it kind of replays into our expe­ri­ence and we feel high emo­tion­al arousal in sit­u­a­tions where we’re actu­al­ly quite safe.

So what this tech­nique does is allows us to engage with the mem­o­ry, which holds a lot of emo­tion, but it allows us to desen­si­tize the emo­tion. So if I was to say to you, Luke, ​“What did you have for din­ner three Wednesdays ago?” what would you say?

Mason: I have no idea.

Carthy: Great. Because there’s no emo­tion­al cur­ren­cy asso­ci­at­ed with that mem­o­ry. But if I said to you you know, ​“Tell me about the best hol­i­day you’ve had this sum­mer,” or if I said, ​“Tell me about the best job pro­mo­tion you ever got,” or I asked you about a very spe­cif­ic sit­u­a­tion where there’s a lot of emo­tion­al con­nec­tion, it would come back to you in full Technicolor. And that’s kind of how neg­a­tive expe­ri­ences work as well. There’s so much emo­tion asso­ci­at­ed in that moment of shock or trau­ma that it keeps replay­ing on our expe­ri­ence. So what we do is we kind of avoid it, we run away from it. And EDMR is a way for us to real­ly stop run­ning away from it, run­ning metaphor­i­cal­ly back towards the emo­tion, but just desen­si­tiz­ing in a way so it becomes like that mem­o­ry of what did I have for din­ner three Wednesdays ago? Well, I can’t even remem­ber? It does­n’t come back up into my experience.

What Psious have done very effec­tive­ly is they’ve pro­vid­ed an appli­ca­tion now where you can put the head­set on, and what it does is it takes you into a calm­ing expe­ri­ence, you go through the process of mov­ing your eyes back and forth. It just leads you through this kind of like a med­i­ta­tion, I sup­pose. But it’s a way of desen­si­tiz­ing the fear asso­ci­at­ed with pre­vi­ous trau­ma and pre­vi­ous shock.

Mason: Now, do you think that these tools could be ever used for pre­ven­ta­tive med­i­cine? You’re talk­ing about some of these sta­tis­tics around men­tal health. I mean, how do you kind of get in there before any of the bad stuff starts hap­pen­ing? Could VR be a poten­tial solu­tion to that?

Carthy: Absolutely. Absolutely. I mean, the cur­ing fears and pho­bias is not pre­ven­ta­tive. It’s work­ing with peo­ple who have already expe­ri­enced a trau­mat­ic events or some sit­u­a­tion or a con­di­tioned response that they’ve learned from their envi­ron­ment or from the peo­ple around them. You know, depres­sion, psy­chosis, most of the men­tal health dis­or­ders that we have are very much set up in a med­ical mod­el, the cura­tive model.

But these tech­nolo­gies and where kind of this vir­tu­al real­i­ty is feels real. I think we could get into a sit­u­a­tion where peo­ple are using it from a pre­ven­ta­tive per­spec­tive. And whether that means cre­at­ing some new envi­ron­ments that will allow peo­ple to devel­op emo­tion­al intel­li­gence, for exam­ple, games that are asso­ci­at­ed round increas­ing emo­tion­al intel­li­gence… Like, focus­ing on I don’t know, build­ing the com­pas­sion­ate self. Or work­ing on what your val­ues are, what your strengths are. You know, there’s so many actu­al pos­i­tive psy­chol­o­gy inter­ven­tions that could be so eas­i­ly trans­lat­ed into the vir­tu­al environment.

Mason: But I won­der if there’s one step fur­ther. If it could be almost build­ing a immune sys­tem toward some­thing like depression.

Carthy: Yes.

Mason: So an ear­ly warning—

Carthy: Yes.

Mason: —sys­tem, essen­tial­ly, so you’re able to rec­og­nize the trig­gers before you get to the point where you’re sit­ting in your office say­ing, ​“Look I have this thing now.”

Carthy: Yeah, absolute­ly. I mean, that would just…it’s an excit­ing and a big piece of work for some. It’s the gam­i­fi­ca­tion of try­ing to get peo­ple into a sit­u­a­tion where they’re focus­ing on build­ing that emo­tion­al immune sys­tem as much as they’re focus­ing on build­ing a phys­i­cal immune sys­tem. That they real­ly are hyper­aware of what it means to be emo­tion­al­ly healthy.

And I think this is about young kids, maybe, or the gen­er­a­tions that are com­ing now. And maybe this is some­thing that when we’re in our fifties and six­ties we’ll look back and say, ​“There it is, it’s hap­pen­ing!” Maybe there’s a younger gen­er­a­tion that will be put into a vir­tu­al world quite ear­ly on and it will just auto­mat­i­cal­ly be able to kind of give them this sense of what it means to be phys­i­cal­ly and men­tal­ly healthy. And there’s a range of games, there’s a range of prac­tices, there’s a range of appli­ca­tions that they can turn to that are pre­ven­ta­tive at stop­ping peo­ple from hav­ing these moments where their quarter-life cri­sis, half-life cri­sis, where they’re turn­ing to med­ica­tion in a moment where they can’t deal with stuff.

And that I think is so excit­ing, and I think there should be, and maybe there is, peo­ple work­ing on it. And that’s kind of the prin­ci­ples of the pos­i­tive psy­chol­o­gy move­ment, which is a move back towards a more pre­ven­ta­tive set of tools and strate­gies avail­able to peo­ple. Which I actu­al­ly feel with the right devel­op­ment com­pa­ny could eas­i­ly be trans­lat­ed into that type of game that kids maybe or teenagers could use.

Mason: On the flip­side, do you think some of these tech­nolo­gies, whether it’s VR or the mobile phone, are caus­ing some of the men­tal health issues that you’re talk­ing about? Do you think there’s this weird feed­back loop between the VR’s caus­ing it, then you have to go into VR to solve it, and then back again, and it’s a con­tin­u­ous, inescapable loop?

Carthy: I’m prob­a­bly not qual­i­fied enough to answer that ques­tion. But what I would say is, just to my own life and to your obser­va­tion, it is clear that this has become a per­va­sive idea, where in par­tic­u­lar kids these days to be stuck on their iPhones, stuck on the iPad, it seems like we have just accept­ed that that’s the way things will be in the future. And it does­n’t seem like it’s some­thing that’s going to change.

I do have reser­va­tions about wear­ables and tools, like tech­no­log­i­cal tools that are sup­pose to tell us how we feel. What that stops us from doing is to be mind­ful enough or to be con­nect­ed to our­selves enough to actu­al­ly be able to judge how we feel in the moment with­out some lit­tle alarm that’s going to go off on my arm every five min­utes. Or with­out some device that’s been designed to help me cope through my life. That just becomes anoth­er exte­ri­or crutch that I believe that I need.

And I do see tech­nol­o­gy, unless we’re very very care­ful about how we set it up, I do see some tech­nolo­gies going down that road. I mean, I don’t know. I’m an 80s child, so even play­ing with tech­nol­o­gy when it came out, you know super Nintendo and Sega Mega Drive—I used to play them for days and hours and stay up all night. And you know, it feels like we will always get these excite­ments. We will always have this dri­ve and this want for these types of tech­nolo­gies. It then comes down to the devel­op­ers, maybe to the gov­ern­ment pol­i­cy­mak­ers or who­ev­er those peo­ple might be, to maybe cre­ate a very respon­si­ble way for us to engage with these types of technologies. 

Mason: It’s inter­est­ing what you’re say­ing about quan­ti­fy­ing some of this infor­ma­tion. I mean, ear­li­er you said that the abil­i­ty for some­one to actu­al­ly see there has been a change in the soft­ware, and the way in which they’re react­ing to some­thing is mas­sive­ly trans­for­ma­tive because ​“there it is, there’s proof, the com­put­er says I’m get­ting bet­ter.” It’s mas­sive­ly psy­cho­log­i­cal­ly impor­tant for them as part of their recovery. 

But then also you’re say­ing that the abil­i­ty to have all this infor­ma­tion is actu­al­ly mak­ing us less aware of our­selves. I won­der where do you think is the right bal­ance between cap­tur­ing as much data as pos­si­ble ver­sus allow­ing some peo­ple to build some form of intu­itive aware­ness. So I won­der if your exper­i­ment­ing yet with EEG head­sets on folks as you’re doing these sorts of ther­a­py ses­sions. The ques­tion is, that amount of data, is it actu­al­ly show­ing us…anything, or is it just noisy at this stage in time?

Carthy: I think it depends on the con­text and the sit­u­a­tion you’re using it. I use VRT the way that a sur­geon would use a scalpel. Only very specif­i­cal­ly, and only when I know it’s going to have a big impact on the per­son. I don’t just wheel it around and use it ses­sion one just so they can get an experience. 

So I think if tech­nol­o­gy is used in that way, very specif­i­cal­ly when it’s going to have an impact on peo­ple’s lives, well I think that’s prob­a­bly a nice way to look at it. You know, just cap­tur­ing infor­ma­tion for the sake of cap­tur­ing infor­ma­tion, using tech­nol­o­gy because it’s a kind of fad or because it’s going to cre­ate some sort of mag­ic wand sense of like, ​“this tech­nol­o­gy is going to fix you,” I don’t like that idea because actu­al­ly that takes away a sense of autonomy—what we talked about the self-determination the­o­ry. I want peo­ple to rec­og­nize that they’re doing it. That’s not the VRT that’s help­ing them over­come their fear. The VRT is cre­at­ing the sit­u­a­tion, the con­text where they are over­com­ing their fear. But that they’re doing it them­selves. That you did it. It was­n’t that some tech­nol­o­gy or some hyp­nother­a­py or some cog­ni­tive wiz­ardry made you feel bet­ter. It was that we cre­at­ed a con­text where you came in and you did it your­self. It’s a way of using tech­nol­o­gy very specif­i­cal­ly to achieve a very spe­cif­ic goal.

Mason: Thank you to Michael for show­ing us behind the scenes of how he uses vir­tu­al real­i­ty as part of his ther­a­py practice.

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