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Implementation of VR therapy isn’t as difficult as you might think.
When it comes to bridging the gap in services available to patients, there is perhaps no area more in need of innovation than mental health services — particularly in overcoming the significant barriers to accessing and participating in therapy faced by many patients. Mental Health Center of Denver (MHCD) is a safety-net mental health provider for the Colorado community, servicing 20,000 patients this past April alone. I spoke with MHCD’s Wes Williams, Ph.D., about programs in virtual reality (VR) that could help the center reach more patients and even enable more patients to succeed in existing programs.
Making the process of treatment more immersive with VR can distract patients from some of the fear they may feel about facing difficult feelings that arise during therapy. MHCD uses VR to help patients to ameliorate that fear and provide skills to succeed in existing therapy programs. As Williams says, “Some of the strategy is that we want to make behavioral healthcare sexy and exciting — something that you are curious about. VR will not be for everyone.”
Safety-net mental health services have more demand than they can ever reach. While it serves more than 20,000 patients in the Denver metro area, MHCD estimates that an additional 20,000-plus community members could benefit from its programs. Between 70 and 75% of the patients served by MHCD receive Medicaid benefits. In terms of the patients who receive services from MHCD compared to the population’s total number of Medicaid patients, “we see fewer than half of the Medicaid lives,” Williams says.
He acknowledged that a challenge for MHCD, along with other mental health providers, is the difficulty that many patients experience in simply addressing their feelings. “The notion of ‘sitting with your feelings’ is a bit daunting for many people,” Williams adds.
Mental health providers sometimes struggle to reach patients who might benefit from mental health therapy. Another equally significant challenge is retention of patients in the program after they’ve received treatment the first time. Do patients keep going? Are they willing to overcome their fears in order to make progress in therapy?
Williams and his team looked at existing technology and decided to work with VR. “Virtual reality is more immediately visceral and emotional than a regular computer-based program or talk therapy, so we have an opportunity to offer patients more a of ‘wow experience’ with therapy,” Williams says, optimistically.
MHCD uses VR as part of guided meditation in Dialectical Behavioral Therapy (DBT) for people with a diagnosis of borderline personality disorder (BPD). This type of therapy has a few parts: mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness. The therapy is especially effective for patients dealing with intense emotions. VR allows patients to simulate growth in a controlled environment.
But a strong foundation of clinical expertise is necessary before any clinic embarks on an experiment with virtual reality.
As Skip Rizzo, M.D., an expert in VR research and therapy, shared, “You need to have that level of clinical skill, to be trained in the traditional method, before you can dig into virtual reality.” Innovation in mental health therapy needs to build on a solid foundation of research as well.
Mindfulness is a core strategy for patients with mental illness, enabling them to cope with difficult fears without becoming distracted by outside sources. Increasing utilization of mental health treatments that have established efficacy, such as mindfulness practice, is the main goal of MHCD’s technology experiment. As such, MHCD has selected meditation as a standard part of its treatment.
The center has an existing high-fidelity program of six months; It recommends that patients enroll in the program twice. A core component of this VR therapy is mindfulness, using headsets and guided practice. Patients with BPD have more difficulty with affect regulation and learning skills, so learning to be present with their emotions is a core component to program success — and meditation has been part of that formula for “a long time,” Williams explains. The ability to master mindfulness early on in the program is a strong predictor of success.
But not everyone graduates from the program; some drop out. Nevertheless, Williams remains confident in the program’s potential for success. “Getting the emotional stability that mindfulness can bring early in the program can impact patients’ overall success,” he says. “We think that running the mindfulness experience through the VR program will make patients more open to other parts of the program.”
Is VR meditation better than regular meditation? It’s hard to say. The experience might be no different from regular meditation for some patients — but other patients who aren’t ordinarily inclined to meditate might be more likely to stick with it due to the cache of VR. “VR adds a bit of stickiness to the treatment, to solidify a great practice,” Williams says.
When looking at how to increase access to mental health services or increase the likelihood of a patient completing the program, operations are key. Since the clinical basis for MHCD’s DBT program for patients with BPD was well established, operational technicalities were a large consideration for the clinic as it planned its VR program.
Williams stresses the importance of focusing on the “hows” of implementation. How will MHCD get the technology to patients? How will that look in treatment? And finally, how will they know if treatment is effective? The organization needs a way to determine whether a given pilot is something worth scaling or if it is just a distraction for patients.
How a given program starts can have a huge impact on whether it helps patients and is financially manageable. This is an issue on the macro and micro levels: For instance, issues such as headset inventory and cleaning costs consistently need to be addressed. In addition, there are several cohorts running through the treatment program at any given time, and planning for the dispersal and usage of technology must be considered.
MHCD recently decided to add a new feature to a group that had already completed its treatment: “Graduates” of the DBT therapy group now come in for what Williams calls “a refresher.” Initial trial of the VR program will start with them, so staff feels comfortable leading meditation with this new technology. Implementation begins this month, June 2019. Once staff is sufficiently familiar with the relevant technology and it is a seamless part of therapy, new patients will receive VR therapy as part of their orientation.
In addition to programs for patients with BPD, Williams and his team are looking at using structured virtual healthcare to improve intensive case management and outpatient services. With an organized protocol for care, the need for intensive work with a therapist, physician or clinician can change. MHCD intends to use exposure therapy and behavioral therapy to help with peer support groups for conditions like fear of heights of social avoidance. The protocol doesn’t require a trained therapist to do that work.
Peer support and virtual reality used together offer several benefits. They can expand the peer practice and involvement for their work. Peer groups also work well with very established programs; peer leaders can provide patients with hope and serve as successful role models. Each individual who provides the therapy does not need as much training because the clinical practice is built in; thus, this care is more cost-effective than hiring new therapists. And most important, from a qualitative perspective, the experience is better for patients — and momentum improves in peer support groups.
The effectiveness of technology can be measured in several areas, including adoption and outcomes. Without measurement, the act of innovation is effectively throwing money down a shiny technology toilet.
Mental Health Center of Denver plans to use patient and therapist reported outcomes to assess if VR programs are successful in providing a meaningful therapeutic environment while minimizing distractions. In addition to feedback from reported outcomes, show rates for therapy and graduation rates for the program will be under the microscope.
In this case, the barrier to entry is staff training and the cost and maintenance of the VR headsets.
According to Williams, the highest risk is that having patients in therapy that doesn’t work is expensive. Fortunately, VR technology is relatively inexpensive.
Looking at adding sustainable improvement through technology — not just now but throughout the year — is critically important. Some innovation in healthcare will use technology to improve stickiness. When programs are more successful, they might not necessarily have a new billing code, but they will improve the outcomes of established therapies. Mental Health Center of Denver is leading in innovation that improves care effectiveness and reaches an increasing number of patients throughout Colorado.
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