Seasoned psychonauts and psychedelic experience facilitators have long emphasized the critical importance of "set and setting" as a psychedelic harm-reduction component and a key factor in supporting positive outcomes. "Set" refers to the mindset and physical well-being of the individual ingesting the psychedelic compound, while "setting" refers to the environmental influences where the psychedelic experience is taking place which include location, sensory inputs (sound, light, temperature, visual, scent, and tactile), and other individuals or life-forms present to name a few.
Some psychedelics have been used for centuries in ritualistic shamanic settings and in nature and even the modern recreational users often aim to plan the setting as close to nature and natural influences as possible. However, the clinical environment, where the modern scientific explorations and practices have been unfolding for the past decade, is devoid of the nature influences deemed essential by many non-clinical practitioners.
While a clinical setting allows for strict control and measure across various environmental variables, In teh absence of settings and influences that promote connection with nature, the full potential of clinical outcomes might indeed be hindered. Enter, virtual reality (VR)! I must admit, as a long-term ceremonial practitioner of psychedelic medicines in natural settings, even the thought of a VR-powered psychedelic experience makes me cringe, however, if these solutions can indeed deliver measurable improvements in clinical outcomes, they're worth considering, not as replacements to authentic connection with nature and mother earth, but rather as environmental design elements to enhance clinical outcomes.
The founders of Enosis Therapeutics, an Australian Psychedelic-therapy VR company recently published a paper outlining how VR might be incorporated into aspects of the psychedelic-assisted therapy process. According to their website, Enosis Therapeutics is aiming to offer VR clinical protocols that employ targeted virtual reality scenarios at specific points of psychedelic-assisted psychotherapy, to improve the quality of the patient experience by allowing the modulation of both internal and external factors.
The authors propose a potentially synergic relationship between psychedelic-assisted therapy as an incredibly promising alternative to traditional psychotherapy treatments and VR-assisted therapy as reportedly one of the most enjoyable and comfortable forms of therapy (Garrett et al., 2017) with one of the highest compliance rates and best therapeutic alliance across all forms of treatments (Meyerbröker and Emmelkamp, 2008; Wilson et al., 2008), even among individuals resistant to other treatments (Riva et al., 2019). They suggest that the dynamic nature of VR and its ability to simulate favorable environmental stimuli, paired with a high level of control offer a strong potential for fulfilling and enhancing significant environmental design factors currently not fulfilled by standard psychedelic-assisted therapy protocols.
They go on to outline the following ways VR can be utilized to support psychedelic-assisted therapies:
1. Mitigate psychological side effects through enhancing the state of relaxation,
2. Help participants sustain their focus on intention by removing familiar cues that keep them tethered to their external world,
3. Encourage entering the inner world of experience by inducing a mindful presence,
4. Deepen the intensity of acute psychological and emotional states via simultaneous targeting of ME-evoking pathways,
5. Prime the capacity to achieve an ASC through familiarization and comfort with the ASC experience,
6. Enhance and maintain a hierarchy-free therapeutic alliance that is consistent throughout treatment,
7. Strengthen resilience and a sense of agency around facing challenging experiences.
They go on to theorize that VR can potentially be utilized to enhance the benefits of altered states of consciousness and mystical experiences by priming the participants to enter and navigate these states with more ease, temporarily distracting overly challenging or adverse experiences and potentially disrupting a stuck state in an experiential loop without terminating treatment. Although fascinating, none of these proposals have been tested in clinical settings and will require further research and trials to validate viability and safety.
The authors also outline potential limits and risks associated with a curated VR experience under a psychedelic influence:
1. Over-Stimulation: The lights, motions, sounds, and even the actual VR headset can present too much of a stimulus to some participants and hence potentially have an adverse impact on the experience by over-stimulating the individual.
2. Accidental Exposure: A traumatic response can be triggered unexpectedly by any relevant cue. Highly immersive VR environments can easily act as a trigger and unintentionally serve content that acts as a relevant clue directly related to the traumatic experience. This can have a significantly detrimental effect, particularly during the vulnerable state induced by psychedelic substances.
3. Leading: In a psychedelic state even the smallest stimulus can have a profound impact on the experience. An experience as immersive as VR will undoubtedly have a significant impact on the individual experience. "A delicate balance needs to be struck between providing mild stimuli to block distraction from mundane external realities and maintaining focus on the intention (guiding), whilst avoiding hijacking the experience and dictating its content (leading)."
4. Distraction: Many psychedelic-assisted therapy protocols involve efforts to reduce outside stimuli to encourage an inward focus and allow the internal narrative to unfold naturally. Authors suggest that VR is best utilized for the post-peak phase of the experience when most of that internal narrative has already unfolded.
5. Cyber-Sickness and Physical Discomfort: VR stimulus can lead to simulator sickness symptoms often involving fatigue, headache, and nausea possibly caused by poor coordination between the visual VR stimulus and the real-life movement. Ensuring the highest quality hardware and software are being used and offering personalized adjustments for maximum comfort are important to mitigate adverse experiences associated with cyber-sickness.
6. Resource Limitation: introducing VR technology adds new complexity to the delivery of an already scarce treatment option by requiring that therapists are trained and resourced to navigate the new technology. In addition, VR also introduces a potential distraction into the therapeutic process.
7. Commercial Interests: VR was not developed as a therapeutic system and its use in mental health is largely unregulated and numerous VR products that target therapeutic, or well-being applications have not been scientifically tested or validated. The authors call for "an urgent need for careful evaluation, ideally via a scientific, peer-reviewed process. Additionally, VR models should always be supplied with robust protocols that consider application, timing, technical requirements, mitigation of potential side effects and response to adverse events, among others."
While VR is a new and exciting technology, its long-term effects on the human brain, nervous system, and psyche are unknown and not studied. There are serious ethical considerations that must be considered when combining an immersive experience such as VR designed by a 3rd party with a highly-suggestable brain state associated with psychedelic altered states. This space must be studied extensively and regulated heavily to reduce harm and abuse potentials.