Navigating the Medical Metaverse: Using Objective Measures to Stay on Course

Taxiing

For those of us who pioneered VR therapy three decades ago, the ability to incorporate in-person VR, teleVR, and the metaverse to allow patients to access effective VR treatment wherever they are located was a distant dream. This tribrid VR therapy ¹ modality is only possible now because technology has flown so far, so fast.

In the 1990s, by monitoring and replicating objective physiological findings during exposure, researchers were able to demonstrate that the emotions experienced in VR can be as authentic as those in the real world. ² For example, I first noted the advantages of physiological monitoring and biofeedback during early VR treatment sessions in 1996. ³ And in the first issue of this journal 2 years later, we published a paper examining the early success of the incorporation of objective metrics from physiological monitoring when using VR as a psychotherapeutic tool. ⁴

At the time, it was evident that certain cumbersome technologies (e.g., heavy headsets; sticky, wired sensors; and image lag) could cause discomfort, sometimes limiting session duration or reducing the sense of immersion required for effective treatment. In addition, the expense and size of some VR and monitoring equipment limited accessibility to what was clearly becoming a valuable, effective form of treatment.

Takeoff

Despite these limitations, therapists and patients alike sang the praises of VR therapy. Research accumulated, and popularity increased. VR therapists liked the fact that, unlike traditional visualization exercises that occur inside the patient's mind, with VR they were able to see exactly what the patient was seeing in real time and then match that input with the patient's physiological responses, generating insight into what was triggering emotional responses and how effectively the patient was engaging with the stimulus provided.

Moreover, physiological monitoring enabled therapists to ensure that patients did not become overwhelmed or re-traumatized during exposure therapy. These measures helped providers develop personalized protocols that progressed at each patient's pace, creating a safe space to process complex emotions.

Objective metrics also become especially useful during treatment sessions with patients who—due to factors such as trauma or neurodiversity—struggled to identify or express their emotions accurately. In addition, allowing therapists to access objective data on measures such as skin conductance and heart rate could improve treatment efficacy by giving the clinician insight into a patient's emotions during a session without having to interrupt the therapeutic flow.

In Flight

Now technology has evolved to include smaller, more comfortable sensors and feedback devices, allowing clinicians to both provide stimulus and collect physiological data from their patients in a less invasive way. Contemporary monitoring devices are smaller, less invasive, more accessible, and more connected than ever before.

Metaverse wearables, some as comfortable and unobtrusive as a common wristwatch, can collect heart rate, skin conductance, respiration, and other biometric data and give real-time feedback about an individual's physiological reactions. Beyond that, while most traditional VR and extended reality systems provided only visual and auditory input, wearable devices worn on the human body can not only monitor dynamic information, including gestures, eye movements, and the posture of the human body, but also provide seamless and natural sensing, including tactile-perception or haptic feedback. ⁵

Because hands and fingers provide a highly developed sense of touch and allow for the perception and interpretation of textures, shapes, and temperatures, hand-worn haptic devices in particular could allow for particularly sophisticated interaction and feedback in the metaverse. ⁵ A thin electronic sticker made of a pressure-sensitive material is available for detecting body motions, and wearable sensors and cameras can also be used to analyze gait for diagnosis and rehabilitation purposes.

Neurologists have also found that eye movements can reveal information about our thought processes. So, glasses and contact lenses can act as effective wearable tools. ⁶ Eye tracking can assist therapists in understanding where patients are directing their attention and focus, helping them to identify triggers or areas that perhaps need more work, again enhancing and individualizing therapy. Smart glasses even have the potential to detect microexpressions that are difficult to perceive with the naked eye, collecting information that can augment a therapist's understanding of their patient's emotional state and responses to specific stimuli.

Other potential opportunities to incorporate physiological data include sensors that perform voice analysis to look for changes in speech patterns as indicators of emotional states, and sleep monitoring to determine whether poor sleep is contributing to a patient's emotional stress or lack of resilience.

Finally, incorporating environmental sensors during treatment sessions to record conditions such as lighting, temperature, and ambient noise could assist the therapist in building an ideal therapeutic environment for each individual patient.

The Landing

As usual, advancement doesn't come without a bit of turbulence. While the metaverse offers a more interactive and participatory digital world, it is also a world in which users are vulnerable to surveillance, perhaps in ways they don't yet understand. Because the metaverse promises more personalized, comfortable, and effective treatment options, it is important to prevent this intimate connection from lulling patients into a vulnerable position.

Physiological data can contain much more personal information than a user generally realizes. Eye-tracking data may reveal information about a user's “biometric identity, gender, age, ethnicity, body weight, personality traits, drug consumption habits, emotional state, skills and abilities, fears, interests, and sexual preferences.” ⁷ Some eye-tracking measures could even be used to diagnose specific physical and mental health conditions.

Companies are counting on the idea that users will hand over such personal information without hesitation. Meta, for example, has already patented technology to build both eye tracking and facial expression monitoring into their optical equipment. ⁶ And while lawmakers in the European Union are taking steps to protect users with their Digital Markets Act and Digital Services Act, ⁶ there is not yet any infrastructure to follow through on enforcement.

In light of this, patient education is key. Lawmakers, mental health professionals, researchers, and technology experts will need to band together with patients to ensure that therapeutic interventions in the metaverse are performed responsibly and ethically, with attention to data privacy, security, and confidentiality, forming a sort of “air traffic control” for the therapeutic metaverse. If we want to use technology to humanize healthcare we need to remember to treat patients like the humans that they are, ensuring them a gentle and safe landing in any destination.