This theory-building paper (2018) proposes the benefits of integrating virtual reality (VR) experiences with psychedelics in order to provide the most effective intervention for certain mental health disorders. The authors discuss three main benefits of integrating these interventions: 1) increases in the efficacy of each individual intervention, 2) increases in specificity and 3) the therapeutic effect can be achieved while using lower doses of a given psychedelic.
The increased prevalence of various psychiatric disorders continue to concern. Promising results are starting to emerge from recent experimental interventions employing VR, and psychedelics, individually. We propose that for certain pathologies researchers need not bother themselves as to which medium offers greater hope. Instead, we hypothesize that the most effective interventions shall necessarily come from a composite approach utilizing both. Traditional medicine adopts similar such synergistic strategies. Combining codeine and acetaminophen increases the analgesic effect. While research into the therapeutic effects of novel interventions using VR and psychedelics, independent of one another, is still in its infancy, we believe that the increased utility of a dual approach justifies closer examination without delay. We posit three main benefits from this integrated intervention. Increases in the efficacy of each individual paradigm due to synergistic coupling, and increases in specificity due to the ability to tailor bespoke therapies for particular individuals and groups, are achieved directly. Such increases in efficacy consequently lead to the third benefit of allowing a therapeutic effect to be achieved while using lower doses of a given psychedelic compound.
Moroz and colleagues situate their paper at the intersection of two emerging therapeutic technologies: highly immersive virtual reality (VR) and renewed research into psychedelic medicines. They note that both modalities individually have shown promise for treating a range of psychiatric disorders—examples cited include psilocybin and LSD for depression and anxiety, ketamine for rapid antidepressant effects, and MDMA for PTSD—and argue that VR similarly offers therapeutic potential because it can reliably manipulate sensory input to evoke immersion and presence. The authors emphasise that both approaches are constrained by setting and stimulus control, and they highlight a conceptual gap: prior work has considered VR and psychedelics separately rather than as intentionally combined interventions that might interact synergistically. The paper sets out to propose and reason through a composite therapeutic approach that deliberately combines VR and psychedelics. The central hypothesis is that such a fusion will yield three principal benefits: (1) synergistic increases in the efficacy of each modality through mutual enhancement, (2) greater specificity by tailoring virtual environments to individual pathologies, and (3) the possibility of achieving therapeutic effects using lower psychedelic doses. The authors suggest that these combined interventions could be particularly valuable for disorders where specific sensory stimulation and maximal immersion are therapeutically important.
Papers cited by this study that are also in Blossom
Berman, R. M., Cappiello, A., Anand, A. et al. · Biological Psychiatry (2000)
Bouso, J. C., Doblin, R., Farré, M. et al. · Journal of Psychoactive Drugs (2008)
Carhart-Harris, R. L., Kaelen, M., Whalley, M. G. et al. · Psychopharmacology (2014)
Carhart-Harris, R. L., Bolstridge, &. M., Day, C. M. J. et al. · Psychopharmacology (2017)
The extracted text does not report empirical methods or an original experimental protocol; rather, the paper is a theoretical and programmatic proposal outlining how combined VR–psychedelic interventions could be developed and tested. Moroz and colleagues draw on prior findings from VR therapy and psychedelic studies to construct a rationale and then propose practical design elements for future trials and clinical implementations. Key components of the proposed composite intervention are described in operational terms. The authors recommend maintaining the physical safety of a sterile medical setting with an accompanying psychiatrist or psychotherapist, while having patients don head-mounted displays to enter tailored virtual environments. Therapists could be present as avatars, and VR content would be selected or designed to target the cognitive and perceptual features of a specific pathology. The intervention logic emphasises maximising presence in VR while exploiting psychedelics’ capacity to heighten suggestibility and reduce reality-testing, thereby facilitating deeper absorption. For translation into clinical research, the paper outlines a phased testing strategy rather than concrete trial data. Initial testing would use healthy volunteers to establish tolerance and to quantify how different psychedelic compounds affect sense of presence. Subsequent stages include Phase 2 with patients who previously responded to drug-only treatments to evaluate added efficacy, and Phase 3 targeting treatment-resistant cases. The authors also propose screening phases to select optimal virtual environments and avatars, and suggest applying established tools and frameworks in the design process, for example the Chou–Talalay method for combining interventions and the German VR Simulation Realism Scale to rate virtual realism. Safety and mitigation strategies are presented as integral parts of the method proposal. The authors recommend substantially reduced psychedelic dosages (below levels in common safety guides) to favour immersion in the externally provided VE rather than purely internally generated imagery. Continuous clinical supervision, avatar-mediated therapist contact to reduce removal of the HMD, and careful participant screening are recommended measures to reduce risk.
The paper does not present original empirical results. Instead, the authors collate and reference prior findings and use them to support the proposal that VR and psychedelics can be complementary. Cited observations include: psilocybin and LSD have demonstrated reductions in depressive symptoms and anxiety in existing studies; ketamine (a dissociative) has rapid antidepressant effects; and MDMA has shown beneficial effects in PTSD. The authors note that virtual reality exposure therapy (VRET) has an established literature showing utility for many specific phobias (for example aviophobia, acrophobia and social phobia) and that immersion and presence are key moderators of VRET efficacy. Several quantitative epidemiological figures are cited to motivate the need for novel treatments: the prevalence of depression in the US reportedly rose from 6.6% to 7.3% between 2005 and 2015, with a larger increase among 12–17 year olds from 8.7% to 12.7%. Beyond these numbers, the paper summarises qualitative and mechanistic claims rather than presenting new measurements: psychedelics are characterised as desensitising reality-testing circuits and increasing absorption and suggestibility, while VR is presented as an instrument for delivering precisely controlled, pathology-targeted sensory stimuli. The authors articulate the theoretical advantages they expect from the composite approach: enhanced immersion and presence due to pharmacologically increased suggestibility; increased therapeutic specificity by matching VEs and avatars to the disorder; and the potential to reduce psychedelic dose while maintaining or improving outcomes. No effect sizes, confidence intervals, or statistical analyses are provided because no new trial data are reported.
Moroz and colleagues interpret their synthesis as a rationale for pursuing careful experimental work combining VR and psychedelics, but they present this as a nascent and speculative endeavour that requires rigorous testing. They acknowledge the infancy of both research domains and the compounded uncertainty of bringing them together, noting that technological and regulatory constraints have historically limited progress. The authors argue that these limitations are not reasons to delay exploration; rather, they call for cautious, staged experimentation to establish safety and efficacy. Potential risks and counterarguments are explicitly discussed. The authors concede that combining two emergent modalities could produce unforeseen interactions, and they note the possibility that aspects of therapeutic utility could be lost in combination. To mitigate hazards, they recommend lower psychedelic dosages, continuous clinical supervision, and virtual therapist presence to prevent patients from removing head-mounted displays. They also address a possible loss of placebo expectancy when patients are taken out of a clinical environment into VR, arguing that the complexity and intensity of psychedelic procedures may still maintain therapeutic expectation and that an overly clinical environment can itself provoke anxiety. In terms of implications, the paper suggests that composite VR–psychedelic interventions may be particularly well suited to disorders in which precise sensory manipulations are helpful—examples emphasised include specific phobias and body dysmorphic disorder (BDD). The combination is framed as enabling bespoke, pathology-targeted experiences that could facilitate unlearning of maladaptive perceptions and support cognitive reappraisal. The authors call for systematic development of simulations, avatar design, screening procedures, and phased clinical trials, and they recommend outcome assessment through clinical evaluation and self-report during follow-up. Limitations acknowledged by the authors include the lack of empirical evidence for combined interventions and the need for replication and rigorous safety protocols.
The authors conclude by urging development and testing of the proposed composite approach for a range of psychiatric disorders, while indicating a particular research focus on body dysmorphic disorder and various specific phobias. They propose practical steps for implementation: create flexible, pathology-specific VR simulations; run screening phases to match patients with optimal VEs and avatars; design avatars to provide therapeutic guidance; and apply combination-design methodologies such as the Chou–Talalay method. Initial testing should involve healthy volunteers to establish tolerance and effects on presence, followed by Phase 2 trials with patients who previously responded to drug-only treatments and Phase 3 trials targeting treatment-resistant cases. Evaluation is to rely on follow-up discussions, self-report, and clinical assessment by psychiatrists. The conclusion reiterates that acceptance of such novel treatments may be slow but argues that, given rising prevalence of psychiatric disorders, systematic exploration of composite VR–psychedelic therapies is timely and warranted.
The dawn of highly immersive virtual reality (VR) has coincided somewhat with a renewed acceptance of psychedelic medicine research. While VR promised much as far back as the 1980s, psychedelic medicine offered similar promise in the 1950s and 1960s. The labeling of lysergic acid diethylamide (LSD) and others as "drugs of abuse" all but put an end to exploration into psychedelics as possible alternative therapeutic choices. Some 50 or so years later we see the use of psychedelics in medicine gradually shrugging off the burden of taboo. Compounds such as psilocybin, LSD, ketamine, and MDMA offer renewed hope for those suffering from various psychiatric disorders including treatment-resistant depression, anxiety, post-traumatic stress disorder (PTSD), and addiction. The ability of VR to hijack the human sensorimotor system creates a similar novel therapeutic potential for applications in mental health. Among the pathologies put forth as ideal candidates for VR applications are those very same psychiatric disorders best suited to psychedelic medicine. Rather than deciding which novel intervention holds the greatest potential for treatment, we advance a theory that in many cases an optimum solution necessarily incorporates both techniques. VR is at its most useful when immersion, and consequently, the user's sense of presence, is maximized. This psychological perception of 'being in' the virtual environment (VE)can be increased by employing psychedelics due to their inherent ability to heighten suggestibility. The benefits of such mediation are two-fold. While an elevation of presence is our primary goal, we may also imagine increased usefulness of virtual avatars due to a leveling out of the uncanny valley. As with VR, environmental setting and sensory stimuli are everything. Minor changes in stimulus may profoundly alter a users experience. Psychedelic treatments tend to take place within extremely controlled environments. A sterile medical laboratory setting provides the necessary safety required when employing such compounds. Composite treatment solutions employing VR afford similar control of surroundings while adding far greater opportunities to evoke specific cognitive and emotional responses. The ability of psychedelics to increase presence, and the ability of VR to provide controlled sensory stimuli creates the potential for powerful bespoke treatment solutions. The individual interventions not only complement each other but offer synergistic interactions whereby each increases the efficacy of the other. Although 'absorption' (openness to absorbing and self-altering experiences)initially seems like a synonym for 'presence', they are not only different but research has shown no significant correlation. We may argue that a composite intervention involving VR and psychedelics has the potential to take patients beyond the usual sense of VR presence and into the realm of absorption resulting in even greater susceptibility. Current upward trends in prevalence for various psychiatric disordersare of great concern. Speculation continues as to the underlying causes of these shifts while many posit the effects of modern life. This position comes in different forms such as increased social isolation and loneliness, sedentary lifestyles, distractions of modern technologies, and over prescription. The prevalence of depression in the U.S. increased from 6.6% to 7.3% from 2005 to 2015. Even more worrying is the 8.7% to 12.7% change among 12 to 17 year olds. Whatever the factors influencing such swings might be, we must explore all therapeutic solutions, however novel, which offer hope to those individuals and communities increasingly impacted.
Technology is finally at a level at which fully immersive VR simulations are possible. Successful evocation of immersion and the resulting sense of presence is ultimately dependent upon the incoming sensory stimuli. Visual, auditory, haptic, proprioceptive, and motor cues in the form of efference copy, should closely match expectations within the brain. When VR delivers with the necessary fidelity the opportunity for sensory hijack and immersion is maximized. Incoming sensory stimuli possess an equivalent capacity to make or break a user's psychedelic experience. Switching out Black Sabbath's 'Paranoid', for The Orb's 'Slug Dub' may go much further than effecting the enjoyment of the soundtrack which accompanies their trip. Visual perception, mood, and indeed the character of the entire experience may be fundamentally altered for the better or worse depending solely on audition.
Realities for Good 2018 18 March 2018, Reutlingen, Germany 978-1-5386-5977-9/18/$31.00 ©2018 IEEE In defining VR as a technology which provides a space in which immersive VEs are increasingly possible, we may describe psychedelics as a catalyst which enhances sensitivity to this space. Evolution of interactive technologies shall further boost immersion and presence. What technology lacks, however, is the ability to directly suppress the brain's natural reality-testing circuits. These circuits, which ordinarily serve to protect against immersion, are desensitized by psychedelics. We may, therefore, label psychedelics "pro-immersion" compounds able to increase the efficacy of VR as a tool for good. This increase in efficacy runs both ways. Treatments employing psychedelics to reduce symptoms in the psychiatric disorders previously described have shown promising results. Treatments of this nature tend to be restricted by location and setting due to concerns of safety. The potency of such interventions may be improved for certain individuals using VR. The addition of VR simulations tailored for a given pathology leads to no reduction in safety or control. We maintain the physical setting of sterile medical laboratory together with an accompanying psychiatrist/psychotherapist. The real world set-up shall remain almost unchanged. By donning head mounted displays, however, the patient may by taken to a far more effective VE, and the therapist may join when necessary in the form of an avatar. A carefully constructed VR simulation enables us to strategically guide the experience. In a similar way that music therapy may be applied in order to induce immersive experienceswe may strategically employ VR in order to evoke a specific cognitive response. By targeting a given pathology in this way we may attempt to alter perception in a precisely defined way. Current psychedelic treatments delivered in a laboratory together with a mental health professional have a non-trivial probability of evoking additional anxiety due to increased feelings of self-consciousness. Immersing a patient in VR helps mitigate the effect by decreasingly the overtly clinical nature of their surroundings, and therefore enabling the patient's experience to develop in a more consistently positive way.
The improvements already described offer extra optimism for the success of these promising novel treatment paradigms. Certain psychiatric disorders may not require specific sensory stimulation. Psychedelics alone may be enough to break a patient out of a spiral of delusional or negative thoughts/behaviors. However, it is in those pathologies most benefiting from specific sensory stimulation and maximal immersion which we focus on. In such cases the synergistic fusion of VR and psychedelics offers an optimal therapeutic solution for breaking the delusion and evoking a psychological 'reset'. Phobias can have a debilitating impact on the lives of sufferers. Body dismorphic disorder (BDD) holds a similar power to cause extreme psychological distress. Both conditions offer difficulties in daily functioning by focusing the sufferer in on a specific anxiety inducing delusion. It is the very fact that the misappraisal relates to something concrete which advances these conditions as prime candidates for the prescribed composite intervention. Knowledge regarding the offending misconception allows us to target it directly. Thus far we have discussed VR and psychedelics in very general terms. However, it is in the increased efficacy from specificity (analogous to the improvements in therapeutic selectivity from synergistic drug combinations), which offers such hope for our candidate pathologies. as psilocybin have shown to reduce depressive symptoms and anxiety, as have dissociatives such at ketamine. Empathogen-entactogens such as MDMA have shown similar improvements for sufferers of PTSD.
Specific classes of psychedelics show greater potential as solutions for specific classes of psychiatric disorder. Certain compounds may instead prove extremely counterproductive if utilized for the wrong condition. We have some flexibility regarding which compound within a class, might suit a certain individual, and the level of dosage. Combining with VR greatly increases our possible interventions. As with psychedelics, specific types of VR simulation shall naturally fit some disorders better than others. In treating PTSD we expose patients to a VE which closely mimics the trigger situation of their condition. Combat veterans are taken virtually back to Vietnam, Afghanistan or Iraq. Survivors of the terrorist attacks ofrelive jets flying into the World Trade Center and the ensuing aftermath. Composite interventions of similar specificity can offer hope to those otherwise unresponsive to treatment. Psilocybin only treatments have already been shown to reduce symptoms in those with treatment-resistant depression. Providing a tailored sensory stimulus in order to guide the experience grants both possible symptom reduction in those still resistant to treatment, and a potential temporal improvement in symptom reduction for all patients. One such utility offering VE would include elements of mindfulness meditation which displays potential as a therapeutic solution in its own right. Vipassana (mindfulness) meditation shows similar promise as a therapeutic solution for alcohol and substance abuse, anxiety and depression [1, 2, 26, 52, 53], and stress. For a given individual we may decide the most effective VE should include a virtual one-to-one session with an expert Vipassana teacher, or shared group session. Such a scenario might prove impossible for a patient in the real world. As part of their bespoke treatment they can instead experience the meditation practice in a heightened state of suggestibility, while enjoying the removal of any potentially counterproductive social anxiety. Such an intervention may include a pre-rendered VE featuring a real-world Vipassana teacher such as Matthieu Ricard or Joseph Goldstein. Alternatively, depending on the patient, we may decide that a perfectly designed digital avatar exuding the same level of calm, enlightened, reassuring presence would be preferable. In either scenario we likely evoke a mystical-type experience in a patient. Such quality of experience potentially facilitates yet further long-term improvements in mental health. Beneficial mystical/spiritual experiences of this type are of course possible with psychedics alone. Guiding in this way, however, increases the reliability of inducing such experiences. Our candidate pathologies call for absolute specificity of VR simulation. Virtual reality exposure therapy (VRET) is well-established. The technique has already been used extensively and has consistently shown promising results when applied to phobias such as agoraphobia, acrophobia, vehophobia, claustrophobia, aviophobia, social phobia, and arachnophobia. Although this alternative to traditional exposure therapy methods has shown to be somewhat useful, the importance of maximizing immersion and presence has been identified as key. Previous combined approaches to social phobia have included supplementing exposure therapy with the selective serontonin reuptake inhibitor (SSRI) sertraline. While the combination showed improved efficacy, it also evoked adverse effects such as nausea, malaise, and sexual dysfunction during the study, and significant deterioration in self reported health 28 weeks after cessation of the treatment. Psilocybin offers far more promise as a potential partner to VRET. Unlike psilocybin, SSRIs such as sertraline are not direct 5-HT 2A receptor agonists and so offer none of the associated benefits such as improved cognitive flexibility, associative learning, and cortical neural plasticity. These characteristics directly assist in a patient's reappraisal of their deluded belief. By allowing the unlearning and replacement of inaccurate perspectives, with new less exaggerated versions, a patient is able to break free of their pathology. These same traits enable an openness to fresh perspectives for those suffering from BDD. VR simulations might take a number of different guises and shall depend on the individual patient. In general, the benefit lies in the ability to provide patients with solid, therapistindependent information about the misguided mental representation of their body image. One possible simulation could see a patient inhabit a number of different avatars in a given VE. With the freedom to inspect themselves by looking down or in a virtual mirror in a variety of different virtual bodies (including a virtual version of their own), we encourage a realization as to the erroneous nature of their concerns. Additional therapeutic simulations may look to harness the Proteus effect which has already shown an ability to alter perception and behavior in VR users inhabiting avatars dissimilar to their own self. BDD has been associated with incidences of abnormal connectivity in the brain. Although the primary aim of employing a composite psychedelics/VR intervention to BDD sufferers would be to evoke a perceptual change, we may additionally speculate a possible mitigation of the effects of such abnormalities. Psychedelic experience with compounds such as psilcybin and LSD not only increase cortical neural plasticity, but also evoke changes in functional connectivity.
We must consider the infancy of the research which we discuss and look to combine. A great deal remains to be completely established and replicated scientifically and so we may be accused of multiplying this uncertainty by bringing together two, as yet, unestablished paradigms. When contemplating such arguments we must consider the restrictions previously, and indeed currently, put upon such research. Processing power has hindered the emergence of VR while bureaucracy has done the same for psychedelic medicine. Despite these obstacles we still see a growing literature of promising findings. Such is the potential power of combining VR and psychedelics that we may cause concern by promoting this pairing of interventions. Only by careful experimentation shall we truly know the effects of this composite therapeutic treatment. We propose a non-linear summation relating to treatment benefits but it is difficult to accurately predict. Perhaps something is lost in the combination which is not currently obvious to us. Such concerns shall be mitigated by restricting dosage of psychedelic compounds. This restriction shall lie significantly below the levels currently used and detailed in the accepted safety guide. We implement such restriction not only for safety reasons, but to facilitate immersion and presence in the prescribed VE rather than one generated in the patient's own mind. Consequently, we shall hope to experience increased acceptance from internal review boards when evaluating the research. In order to maintain absolute safety we shall necessarily accompany the patient with a psychiatrist or psychotherapist with whom they are completely comfortable. In order to reduce instances of a patient breaking presence by removing the head mounted display, we shall introduce the therapist virtually as necessary using social VR or similar. One might argue that taking a patient out of the sterile medical laboratory setting, and into a VE, risks a decrease of expectation and subsequent loss of any associated placebo effect. We counter such concerns by emphasizing the complexity of conducting safe interventions using psychedelics, which in turn may increase expectation. Additionally, when conducting research with psychedelics we must concern ourselves that an overly clinical environment, exhibiting extraneous medical equipment and personnel in white lab coats, may increase anxious reactions.
We propose a novel combined therapeutic approach for a wide range of psychiatric disorders including depression, anxiety, PTSD, and addiction. We encourage others to explore the usefulness of this technique for such disorders while we focus our attention on providing solutions for sufferers of body dismorphic disorder and a variety of phobias. We begin by developing flexible simulations in order that patients receive the most effective sensory stimulus. Screening phases in the treatment process shall allow identification of VEs and avatars best suited to the pathology, and most conducive to offering the patient an optimally comfortable experience. Avatar design is crucial as this entity shall offer guidance and support while the patient navigates their psychedelic experience. Avatars have already shown their utility in schizophenia treatments. In prescribing composite therapies we shall decide drug, dosage, and simulation combinations in a similar way to drug-only combinations using the Chou-Talalay method. We may categorize simulation settings according to pathology while rating the expected potency using the German VR Simulation Realism Scale. Testing shall initially take place using healthy subjects in order to establish tolerance and gauge the effects of various psychedelic compound on the sense of presence. Phase 2 sees patients who previously responded well to drug-only interventions receive the combined treatment. Here we gain insight into the increased efficacy of com-bining treatment paradigms. Phase 3 shall attempt to treat those hard cases who previously exhibited little or no improvement from drug-only therapies. Follow up visits and feedback shall inform how to proceed regarding the future development of composite treatments. The effectiveness of each novel composite treatment shall be assessed by evaluating patients in follow up discussions and will rely upon self reporting and clinical assessment by a psychiatrist. Acceptance of novel treatments of this nature is naturally slow. Psychedelics will take time to become an established part of medicine due to an arguably checkered history and the resulting popular misconceptions surrounding such compounds. Whether or not the adoption of psychedelic medicine proves to be straightforward, now is not the time to resist progressing the knowledge of such novel interventions. The prevalence of depression and anxiety, PTSD, and addictionare all increasing. Effective composite treatments such as those described can raise hope in the individuals and communities currently suffering these pathologies.
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