digital nation - life on the virtual frontier

Getting on Board with VR

Albert "Skip" Rizzo, PhD., a research scientist who helped develop Virtual Iraq, tells how he became a supporter of using virtual reality for therapy.

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For soldiers who grew up gaming, virtual therapy may be an easier experience than sitting ...
A New Therapy for a New Generation
In a moment of downtime, soldiers in Afghanistan play war games on their PSPs.
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A first-person tour through the Virtual Iraq therapy program.
Experience Virtual Iraq


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Q: What's a nice shrink like you doing in a place like this?

RIZZO: This is the most fun a shrink could have, right here at ICP (?). We actually have opportunities here that most psychologists wouldn't have available to them. The ability to work with computer scientists, engineers, experts in artificial intelligence. So our group is, I think, kind of privileged to be able to work with interdisciplinary group on a cutting-edge technology, something that makes sense, too for clinical practice. This isn't just about throwing technology at problems. We actually bring in good psychological science into the mix of computer technology. Trying to make a difference in everyday people's lives.

Q: What brought you here?

R: In the 90s, this technology started to emerge and become more practical and usable. At that time I was doing more clinical work, and sw that my patients were enamored with games. These were folks with brain injuries that were very hard to motivate with traditional methods. And I would see them playing with Game Boys, playing on Nintendo 64 and these kinds of things. And I would see them focused, engaged and it kind of hit me at the time that perhaps a way for clinical practice to move is to leverage new technology, use games to motivate people, to attract them to therapy in a way that they might not ordinarily do for traditional talk therapy. So that's how I first got involved in this area.

I wasn't that old back in the early 90s, but a lot of my clients were teenagers and early-20s males who had had suffered a brain injury due to car accident, motorcycle accident. And observing them, and how they interacted with new technology and games, and to really see that motivation and see that pure drive that these technologies could produce in them. That set off the lightbulb. So in 95, I left clinical work and came to USC and began trying to create a lab that focused on using new technology like virtual reality for clinical purposes. Since that time we've developed applications that address cognitive issues, kids with attention-deficit-hyperactivity disorder, we're currently doing a study with Alzheimers' patients, as well, working in physical therapy, developing game-based interaction devices so people can do physical therapy while embedded or immersed in a game. Make it fun and engaging.

The work with PTSD with we're doing, using a simulation of Iraq as part of the exposure therapy approach. So over the years, the lab has grown and evolved to address the core elements of functioning for humans: cognitive, psychological-emotional and physical.

Q: The PTSD work is a little different from the other stuff. Because the immersion environment is not there in the same way that the physical therapy thing motivates you. What's the genesis of that idea?

R: I think exposure therapy is one of the areas that VR can do really well right now. The reason that we went that route is because the current generation of soldiers grew up digital. And they may be more apt to seek treatment within a treatment environment that has digital technology. And so we hope can draw in folks to treatment that would never go one-on-one, "tell me about your mother" type therapy. Instead this may be a drawing card. As well there's a good theoretical basis for using Virtual Reality for exposure therapy; Particularly with PTSD, where avoidance of cues and reminders of the trauma is part of the symptom picture. So it's a pretty tall order to ask somebody with PTSD to imagine in real graphic detail what they experienced as part of the therapy. And you never know what's going on in the hidden world of imagination. So with VR, we can actually put a person in a relevant simulation. And help them along in how they recount the trauma.

Well, PTSD is in the category of anxiety disorders. And it's sort of the high end of anxiety disorders. On the low end would be simple phobias: fear of heights, feat of flying. In this case, PTSD is typically diagnosed...

Well, PTSD is a diagnosis that's given when someone experiences a trauma that's beyond the realm of everyday normal human experience. And they usually feel helpless, they feel fear and terror. And what happens with PTSD is, they develop symptoms of avoidance of anything that reminds them of the trauma. They have re-experiencing events, nightmares and flashbacks. They're hyper-vigilant. Very jumpy, edgy. Somebody closes a door, and they jump out of their skin. And a whole set of other symptoms that occur based around those core symptoms.

Exposure therapy is an approach, a cognitive-behavioral therapy that's been around since the 50s or 60s, but really formalized in the 80s with the work of Edna Foa. And basically what that is, is, exposure therapy is an approach where you gradually reintroduce the person, in a very gradual fashion, to the elements of their trauma experience while they narrate and tell their story. So that's a key element here, that they have to emotionally process memories by telling the story of what they went through. And traditionally, since the 80s, it's been done solely in imagination.

Now, with VR, we can actually put people in simulations that are relevant for a person's trauma, and ever so gradually introduce elements into the simulation that raise anxiety gradually, and as they start to feel more anxious, and they're encouraged to stay with it and tell their story, you see the anxiety start to, what we call habituate. Or the patient gets used to what they're experience, experiencing, and you see that you do this repeatedly over time, and the trauma memories almost become more boring than fearful. And then over time, maybe 10 sessions, you start to see real serious differences in how a person interacts in their everyday life. They can go to places that they normally avoided. They don't have the night terrors or the flashbacks. They can talk to people. They can talk to loved ones about what they went through.

Because a lot of times, folks don't want to, when they get back from extreme combat, they don't want to talk to people to tell people about what they went through. Because, 'they don't get it. They don't understand.' And that's primarily because they're so traumatized by the memory they don't think anyone could appreciate what they went through. By the time you go through this kind of therapy, you've talked about it, in a safe, supported environment, with a therapist that's trained, a well-trained therapist, and they start to feel more comfortable. This is part of the homework assignments that we have folks do is to call up a significant other, an old friend. And begin to tell them about the experience, try to transfer from the therapy setting to the real world setting.

And I want to really underscore here that the technology doesn't fix anybody. It's a tool in the hands of a well-trained clinician. We're using technology to advance existing knowledge about what works in therapy. It's not a self-help tool, it's not an automated treatment. We're not aiming to eliminate a therapist. We're looking to give a therapist tools that extend their skills. And that's what virtual reality can do very well, I believe.

Q: So it sounds like VR brings two things. One, it might attract people who might not engage in this kind of therapy to actually do it. And tow, it augments the kind of communication that goes on between the patient and the therapist. Are both of these intentional?

R: I think the first part is to create an environment that gets the patient to bring out their memories. To emotionally process them with a therapist. And beyond that, you build the communication between the therapist and the patient as a shared experience. The fact that we're using modern graphics and sort of game-based technology is an added feature that hopefully will draw people into treatment, because they can say, I'm going to do our virtual-reality therapy session, rather than, I'm going to go talk to my shrink about the problems I have. Or about my mother. Whatever. I don't have a problem with my mom, I just use that as an example.

Q: Where is this used now, and what evidence do you have that it works?

R: Right now, the Virtual Iraq and Afghanistan are in about 30 sites around the country. A couple of sites in Europe now. And it's in military installations, VA hospitals, and university clinics. The data that we have is still preliminary but very encouraging. We have an open clinical trial that was conducted out of the naval medical center in San Diego with 20 patients that completed the full course of treatment. Of which, at the end of treatment, 16 no longer met the criteria for PTSD. It's an open trial, it didn't have a control group, so it's still preliminary. But the controlled research, the randomized control trials, are now ongoing, so you can randomly assign somebody to imaginal exposure versus VR exposure versus waiting list control group. And the work is ramping up. So what we're getting as incremental evidence to support its use. Also in another open clinical trial at Ft. Lewis, directed by Craig Reeger (sp?), showed similar findings to the San Diego group. There's some previous work with VR for PTSD, the work of Joanne DeFitti (sp?) in New York City with World Trade Center victims, where she did a controlled trial and compared it with a waiting list control group, and showed dramatic improvements with the VR exposure and in that study, a significant percentage of the people that achieved success with VR were people who had tried the imaginal approach previously with no therapeutic benefit.

Q: So then what was the process by which you sold this to the military?

R: It was a hard sell initially to get the military to buy into this. Originally we came up with the idea at the end of 2003. And built a prototype off a common game that was available on the Xbox. And applied for funding, and were basically told, we're probably not going to need this. Mission accomplished. But then around July of 2004, an article came out in the New England Journal of Medicine, led by Charlie Hoag's group, that laid out, it was a call to arms, basically. It was a study that looked at incidence of PTSD with returning vets from Iraq and Afghanistan. And essentially said, look, we do have a significant mental health problem on our hands, and it needs to e addressed. So at that point, because we had a prototype that we'd been showing around, we'd applied for funding, and we were contacted by the Office of Naval Research, and they ended up funding the last couple of years of our work to develop the application beyond the prototype phase, and conduct our initial clinical trial in San Diego.

Now, along we way, we would run into roadblocks in a lot of ways. It's a Catch-22 when you're doing clinical research, because if you have an innovative approach like this, they want to see the data, otherwise they call it an experimental treatment. It's kind of like the insurance companies, you know? But if you don't have the funding, you can't get the data to document that it works. So, you know, we've fought and struggled for the past couple of years, but now, with the emerging data, and with the widespread exposure to the application that's occurred, people are getting that this is not a sci-fi, Star Trek, holodeck dream. This is functional technology.

I like to say that just as you would prepare a pilot to deal with the experience of wind shear when flying a plane, by using a simulator, we can do the same thing with virtual reality. It's essentially a simulation you can put people in these environments and systematically control what happens to them and so when I go to psychology conferences and people are skeptical, I say, when you're flying home, do you hope that the pilot flying the plane has had 20 hours of experience in a simulator on how to deal with wind shear, or would you rather he read it out of a book, or saw somebody else do it? So I think that there's a compelling case to be made for this, but the military communities, and all the medical, mental health communities are always a little cautious about something new. And that's perhaps prudent. So, it's been a bit of a struggle. But I think we've gotten past the tipping point where people accept that this is something that can make a positive difference.

R: What I have seen with my experience with the military so far is that they are very concerned with what happens to people when they come back from Iraq or Afghanistan. I think there's a bureaucracy that makes it challenging to introduce new things. But to a one, every person that I've worked with from military installations and higher echelons within the military has made this like their primary focus, that we've gotta take care of these guys. You don't hear about that a lot. But I do see that quite often.

Q: It seems like there's two stages of customization with this tool. One in the sort of creating it through feedback, and the second is actually designing this experience with what an individual needs for their story. If you could talk about this user/client-centered development approach.

R: What we've done to build this application, and I want to preface this by saying that you can't build something like this from the walls of the ivory tower. Essentially what we've done is, look at a lot of film clips, a lot of still photographs of relevant environments, and use that as a start point. But then we sent the system to Iraq in 2005 and then continued gathering feedback from returnees at Fort Lewis, and their feedback was essential for actually making this a useful application. So to hear stories about way that IEDs were hidden, or what the architecture was like, or the smells were like. We could never have gotten any of that from cruising the Internet or anything. So we essentially relied on really user-centered feedback from boots on the ground, telling us what we did right, what we got wrong, and continue to evolve the application in that fashion. Now we're getting information from actual patients that are doing the system, so they're saying, "this isn't quite right," or "this is really good," and we have a list this of things we want to add and change and put into the environment to make it more relevant for more people.

Q: And how do you build the specific simulations for the exact patient you're working with?

R: Well, the simulation has a standard base. So you're in a Humvee, going through the desert or a mountainous environment, or you're in a city. From that base, then we have hot zones throughout where we can introduce stimulus elements, an IED a vehicle blowing up, an insurgent coming out of the palm grove and shooting at you. Getting attacked while you're going under a bridge. At a checkpoint. So we're able to add these things in on the fly, or take them away,

We've even built an American desert environment, sort of as training wheels, so that somebody can go through Mojave, and there's American signs, and that's how they get comfortable initially, and gives them a little familiarity with the technology. And then as they get through that, and feel more comfortable in that environment, then we might move them into the Iraq scenario, but at a very low level. It may have nothing going on. Just the sound of wind, parked by the side of the road. And we can add in the Humvee motor. We can turn on the bass shaker and get a vibration. We can have a gunshot in the distance, a ricochet. And we can add in an IED or a vehicle blowing up, or a whole variety of these features. And all these features are thing that people told us were they things that they have difficulty with in Iraq. One of the things that really struck me is we had a loop of an ambient city environment, of sound. And there's a baby crying in the background. And we didn't intentionally put that in. But that turned out to be extremely evocative for many of the people trying the application, that baby sound haunted me. Sometimes you get lucky, sometimes you gotta work hard.

Q: You suggested that it's also used for preventative maintenance on soldiers. Tell us how does that use work. So if the soldier isn't bringing up a memory, saying, then he was here, this was there, if you're not building it around them, what's that like?

R: If There's been a lot of interest over the past couple of years in what people refer to as stress inoculation. And that is putting people in a simulation, whether that's a mock Iraqi village out in a desert, or in a warehouse, or it's in a Virtual Reality headset, to put people in environments that challenge them to some degree before they go into combat, so that they might be somewhat prepared for what they might see when they get to the real thing.

I think that the idea of exposing people in advance to some of the ugliness of war may be helpful, but I think what you need to do hand in hand with that is address the cognitive coping strategies that go along with that. How does someone interpret or appraise a situation where there's a dead child, or where they may have mistakenly shot one of their own comrades, or seeing a good friend die. How can you prepare somebody for that possibility, and how do you prepare them for being able to cope with it? Now, if you're talking about a lot of young soldiers going over who haven't had a lot of experience in the world, they may not have evolved the kinds of coping strategies of somebody who's a bit older, that's had the wear and tear of everyday life on them, may have learned. So to develop ways for people to interpret their experience to go hand in hand with the exposure, maybe the approach to go. Because, you know, as a good cognitive behavioral psychologist, I believe it's not just the events in the world that produce the emotion, but what you tell yourself about those events. So the same even with two different people, can have two different emotional reactions. And so we want to try to equip people that are going to be put in these horrific situations, ways to cope with what they may experience in advance. And I think the military has taken a very strong look at this. Because they're very concerned with having the best-prepared military, not only in combat operations, but in psychological adaptability to extremely stressful circumstances.

Q: In your opinion, in some cases does it damage people? I mean, you create a simulation because a soldier has to be able to shoot a woman or a kid if that person might have an IED, or if they do. So in theory, the simulation would be designed to help a person overcome a natural instinct against shooting a child, because that child is going to blow them up. Is that good for a person's psyche?

R: I think you bring up an extremely important point here. And that is, the technology is neither good nor bad, it's how it's used and applied. And in this case, when you're dealing with powerful simulations of possible ambiguous events where there isn't a right answer. There isn't a good answer. It's just how you cope with it. So I think there's always this potential. And there's this potential in somebody watching a movie, there's always the potential that they're going to take what they see from media, and have it impact them in a way that might not be what we planned for. And this is the basis of, if we knew the answer, we wouldn't need to do research. And that's why we need to do research on these kinds of things. My gut feeling is, I think the technology's powerful enough to help heal people. But I don't think it's powerful enough to take an ordinarily good person, and turn them into a sociopath.

Q: You don't think this is the new MK-Ultra Super-Soldier experiment?

R: I don't think this is like a Clockwork Orange or any of those kinds of negative conditions. Because people put a lot of thought into how you're going to be using the technology in ways that are going to be safe and lead to a positive outcome. You know, I don't think the technology would do anything to alter a person's judgment beyond what they may get from their actual basic training. But once again, that's speculation. And that's why we need to do research in this area. You know, there's always a lot of this talk about, you heard about this with the video game experience with children. Are children going to grow up to be killers if they play a lot of combat games, or, you know, any game. Halo or whatever game. That isn't found to be the case in the long run when you do good controlled studies. You may see an immediate reaction after playing a violent video game or a child being less pro-social. Or they may be more quick to snap, in the short-term. But there hasn't been the kind of research needed to say that kids who play a lot of video games, violent video games, are going to turn into sociopaths later on in life. I think people do have the frontal lobe function to know the difference between what they do in a simulation and what they do in the outside world. And the consequences that are different in both those situations.

Q: Well, what's the difference between desensitization and habituation?

R: Well, we use the term habituation when we want to help people overcome traumatic events and help them to emotionally process bad experiences. Now, desensitizing somebody, people use the terms interchangeably. When I think about desensitizing somebody, I think about making them a little more callus, a little colder, a little more indifferent. And that's not the goal of even the stress inoculation work.

It's not about indifference. It's about being able to make sound judgments and being able to live with your judgments after the fact. So I think this is, this gets into the area of philosophy of, can we, is it ethically proper to even have war, or to train people to participate in war. And there are always going to be differing points of view on that, but the reality is, it does happen, that we do engage in war. Humanity hasn't evolved to the point where that's not necessary. Our end of it is to try to help people make right decisions, and to be able to live with the hard decisions that they had to make in an almost impossible situation like what you might find in combat. There's no right or wrong answer. There's just hard answers.

Q: So far, you haven't run into a Doctor Evil, or a General Evil, who's like, get them so they can do this horrible thing. It's more, get them so they can still function while this horrible thing is going on.

R: I think that's exactly right. And trust me, I'm a pacifist. I don't believe war is the solution to things, but unfortunately, this is the state of affairs that we're in. I haven't run across one person in my experience with people in the military that believes we want to turn human beings into war-fighting automatons. It's more about helping military personnel make correct and ethical decisions, and hard decisions, that they can live with later on.

Q: What are your thoughts on the fact that it's the military funding, and most interested in the relationship of humans and technology right now. I mean, it's party, there's an economic breakdown so Atari isn't here to say, what's the relationship of human cognition and video games. That it is the military. Is this the way it's always been? That the military funds that then trickles down to the rest of the world, or is this a sign of our times? And how does it characterize the technologies that we end up using?

R: It's a sad state of affairs. But it's a reality, that war is a horrible thing. But it does drive innovation in medicine, in rehabilitation. You can take it back to WWII where the field of clinical psychology emerged after WWI to deal with the many people who came back with what we now call PTSD, but it wasn't diagnosed at that time. Are advances in military medicine spurred on by war. Like so for example in Vietnam, the number of people wounded to deaths was 9:1, I believe. [starts over].

The advances in military medicine can be seen like when you take the Vietnam War, where it was 3:1, three wounded people to one death, and now estimates of 9 or 16:1, so that more people are surviving extreme injury and wounds in combat because military medicine has evolved from that experience. And that of course trickles down to civilian medicine. But there's also the other side of the scale, that people are surviving these horrific injuries, so now there's a motivator to help these folks out when they get back, missing an arm, or multiple amputations, and blindness, a brain injury, a whole, PTSD of course So there's a motivator now, by the government generally, and the military, to come up with the best ways to rehabilitation and intervene with people that have gone through war.

And eventually that will, I don't want to use the word trickle down, but it will be dual use for civilians. But we will see from this war, if you can say, some good in that there's a lot of funding out there to study traumatic brain injury, study ways to rehabilitate it, advances in prosthetic devices, advances in how to treat PTSD, the results of trauma. I wish that that funding was available when we didn't have a war. Because every 90 seconds in the U.S., somebody suffers a brain injury that requires hospitalization and rehabilitation. Well, where was the money for all those folks for the last 20 years? It's only been recently, now that there's been this uptick in funding available for TBI research, that derives out of the war. So it's, excuse the expression, a double-edged sword here of, war is horrible, but it does drive innovation in healthcare and rehabilitation.

Q: Many people, myself included, are concerned about the ways video games and technologies dehumanize us, and separate us, and make us share less intimacies with one another as we go further onto the Internet or away from real experience. At the same time, my experience of the simulation was one of intimacy with you. That felt more intimate that the interaction that we're having right now. Now, explain that.

R: You know, you can trace it back... People have always questioned the introduction of new media for good or bad. For example, in the 50s, comic books were the root of all evil. In the 60s, television was going to lead to the decay of the mind. Rock music in the 70s, you know, on and on and on. And now video games, because they're so popular, are getting the bullseye put on them, so to speak, as a technology that could lead to more harm than good. I don't believe that's necessarily true. I think humans adapt to media, and media, in and of itself, as with any technology, is neither good nor bad, it's the use that it's put to.

So in this case, the use here, and in many other types of applications, I think support communications. Support a bonding that never would have occurred without that technology. Look at people that are on chat groups or email listservs where they never meet a person face-to-face, but they develop a significant relationship with that person. And a lot of times, when they actually meet in person, that relationship continues to endure. It's not like, well, they're cool online, but I wouldn't want to hang out with them at a party. So I think that the fear that technology is going to distance people from each other, I don't agree with that fear. I think that modern technology allows and supports people that would never be connected to form relationships. And expands our boundaries beyond just our neighborhood. Now, if you look at the data, you'll see that the time people spend on the Internet is not just a new, wasteful amount of time. It's time that they're not spending, sitting on the couch watching TV. So they're doing something that's interactive and brings them in a more connected way together with people where geographic boundaries are no matter anymore.

Q: But you're saying also that the technologies coming in to heal the ravages caused by the media before that. TV, de-socialized us. So the Internet, well, it's remedial help. Or this technology in the therapy session, Is it just because we can't do what we could do in therapy 30 years ago, because I'm too mediated?

R: Are we trying to heal the ills of past media forms? I think that when you're talking about television, it's a passive medium. People sit, and take things in. That's not necessarily bad, it's dependent on what the content of what they're taking in. I'll be the first to admit, I've learned more about the history of the world from the History Channel than I ever learned in grade school. So that type of media, I think, has value, and I'm not going to be snobbish and say sit-coms are horrible, or they give people a false view of how people should interact with each other. So I'm not sure if it's so much an ill from past media as it is an evolution of new media. So the new media may cure some of the things that we didn't think were so cool about passively watching the television. But this new media allows us opportunities for interactions with others that were not possible. I'm on music list-servs where, for an old band in the 70s that will remain nameless here, that we, that I love, but not a lot of people like, a progressive rock band. And all of a sudden I find the list-serv, and now here are 3000 people on this list-serv, and they all like the same music, that I didn't know existed, and they like other kinds of music that are the same, and now I feel like I have a few hundred friends that I never would have had before.

Q: Do you foresee a day when people try to replace the human therapist in the PTSD system?

R: I think that some people will believe that you can build an intelligent agent who can replicate what a therapist does. People tried it in 1966, the Eliza Program, that mimicked a Rogerian non-directive therapist. I don't think that's going to happen in our lifetime. People will try it. But for the current 10, 20 years from now, I think as Joe Wiesenbaum said, the developer of Eliza, you never want to have a computer take the role of human friendship in areas where humans are needing care and concern and sensitivity. I'm still old-school like that.

If it brings some level of treatment to people in remote areas, where they wouldn't have access to treatment. Even if it's somewhat limited compared with a real human being, then maybe there's a value to it. I mean, it's always a value judgment here. But, what we develop here, once again, is a tool for a good clinician. It's not a self-help tool or an automated therapy or anything like that.

Some of the feedback that we've gotten from soldiers and also with the sort of emergence of a view that we're going to be spending more time in Afghanistan, has required us to start thinking about, how do we Afghanistan-ize Iraq? Do we just simply add mountains? Do we change architecture? Do we change the language of the characters in the simulation? So we've got a laundry list of, you know, physical setting things that we needed to change, and we've already worked on that.

We have an actual Afghanistan application now, with these things, mountains, and Iraqi - Afghani architecture and so on. But one of the elements that we needed to add more of is more people, more people that interact with you as you're going through the environment. People that can ask you questions, or speak in a different language to you. We need a variety of more injury cases or wound cases. We've been avoiding it, but we need to build children that are dead or injured as part of the process. Because that seems to be extremely relevant, we've avoided that so far.

We need to add things that are very relevant, like for example, at a training last week, I heard from some Air Force people that were telling me what they really need is people that are at field operating hospitals that greet the medi-vac choppers that are bringing in extremely wounded people. Those are the people that are having difficulty when they're coming back. We need to build those kinds of scenarios where horrifically wounded people are being wheeled out of a medi-vac screaming and whatever, all the nightmares you can imagine. We need to build things like that. So we've got a pretty tall order ahead of us. And a lot of subtleties that need to be added - a remote mountain outpost. Like in Afghanistan, soldiers were in remote mountain outposts and periodically have incoming mortars or you see the tracer firings from the mountain across the valley. So we're trying to build things like that. And also, I think that the key thing is to have the virtual humans in the environment have more artificial intelligence so they can begin to play more of a role to interact with you as a comrade or an enemy or a civilian might interact with you.

Q: And then you're doing some civilian applications with this, too, for regular people in car crashes or getting mugged or attacked.

R: We have a civilian driving application right now, but it hasn't been applied for PTSD. It was developed actually to test people in terms of their attention abilities to be able to, how well they can drive. And we also hooked it up so that people after a spinal cord injury could practice using hand controls to drive a car. So that was a pretty cool application. To make into an exposure therapy application would require us now to add the levels like what are in Virtual Iraq. Where things happen that are bad. And you can grade the exposure to those bad things, and that'll be the next step with that application for civilian use.

Q: You do that all with the WTC, the 9/11 thing?

R: My... a colleague that works with us on Virtual Iraq was one of the leaders with the World Trade Center VR application, Joanne DiFitti, she's at Cornell-Weill Medical College in New York City. And they have an application that is of the World Trade Center so you can get the experience of being there, a nice sunny day, nothing happening, no planes in the air. And then gradually the sound of an airplane, and then perhaps a plane flies over, and then all of a sudden a plane hits it. People are jumping out of buildings and so on. So there are those applications.

There's applications for, there's a Virtual Vietnam application that actually came out in 1997. But that's a hard population to work with, because it's been so long since their trauma, 20-25 years, or more. So when somebody's had chronic PTSD for that long, it becomes harder t treat because there are so many secondary problems - substance abuse, marital problems, depression that follows on when you can't work in an environment. Many things that happen. So that's a harder problem now with those soldiers from that war, unfortunately.

The first thing to consider is that, most people, when they hear about exposure therapy, they don't get it. It seems counter-intuitive. Why would you make somebody go back and re-experience a thing that hurt them so badly. And in actuality, over the years, the research has shown that only by addressing the trauma in this graduated fashion, can people begin to heal. So it's not really counter-intuitive, it's a way to get people to emotionally process painful memories that remain locked down and come out in other ways. What we try to do is to present an environment that puts people in at a level they can handle, but then, by their narration, what they tell us about what they're feeling at that time. And also, we have heart rate, skin conductivity, and respiration being monitored, so the clinician can see if somebody is starting to get really agitated.

What we try to do is modulate the anxiety experience so that you feel, you do feel anxiety, but at a level you can handle. And the therapist encourages you to stay with it. Stay with the thought. Tell me more. Tell me a little bit more about this, about that. And eventually you see that anxiety level begin to diminish. The patients will tell us on scale of 1-100, we call it a SUDs rating, Subjective Units of Discomfort. "I'm at a 40." "OK, stay with it," "Oh, I'm at an 80 now." "OK, let's back it down." And you want to keep that moderate level of anxiety there, because only by experiencing that, and having nothing really bad happen, can that anxiety response extinguish, and the person start to habituate. Then you add more elements into the scene.

We have the clinical interface that allows the clinician to add or take away elements. You add something else that's relevant to what the patient's already tell you. And they go through that cycle and continue to do it repeatedly and repeatedly. It's almost like the trauma memories become more boring than anxiety-provoking over time. But over time what you see is habituation, or people get used to it within the session, and across sessions as well. But we monitor what people tell us, their SUDs rating, and what their body tells us with their physiology.

Q: Is it turning off the thou shalt not kill...?

R: You saw this, there was a New Yorker piece about three years ago, is it turning off the Thou-Shalt-Not-Kill switch that leads to a lot of these problems. And there was a rabbi, I believe that was counseling folks, you know, a guy went to him and said, "I've killed somebody. I've violated one of the commandments." And the rabbi said, "No, if you go back to the original Hebrew that was written, it's 'Thou Shalt Not Murder.' The verb in Hebrew is 'murder,' not 'kill.' It's only in the English translation that it went to 'kill.' So that sort of absolves you from, from killing in war as opposed to murder."

Q: Which is nice.

R: I guess [laughs]. It's a way to deal with it.

Q: It's still hard to stab somebody in the chest. It's hard to bring yourself to do it.

R: Can you imagine? I mean, war is so sanitized now, from a distance.

Q: I can do that. Push a button. That's easy. For a patient, what's the experience of putting on those goggles? What do they get from the VR component that they wouldn't get otherwise?

R: First and foremost, there's no doubt that this is hard medicine for a hard problem. And when you put on those goggles and go back to face your fears, to face the horrible events that you were involved in, that's a tall order. That's a hard thing for a person. And patients have to be kind of brought along in a way that gradually brings them to the point that, yes, I can address the trauma. In fact, a lot of times, up until 2003, 2004, exposure therapy, where addressing the trauma is front and center, wasn't used. Because most therapists were afraid. No therapist wants to feel like they're hurting, or putting their patient through any pain.

But the reality is, by facing your fears, and doing it, again, in a safe, supportive environment, in a therapy office, with a good clinician, that's the only way that you're going to be able to get beyond having your fears haunt you for life. So when people come into a therapy session for this, they're apprehensive. They don't often get why they have to do it. So there's a psycho-educational component to explain the process, and then when they go in, like I mentioned we have the virtual Mojave Desert environment. That's like training wheels. To get them back in the Humvee, but in a very safe surrounding, and get them used to it that way.

But the reality is, in exposure therapy, the person has to feel some level of anxiety in order to get better. But not at a level that's going to re-traumatize them. So you're constantly changing things, asking questions, going back and forth. You're doing things in a simulation that I believe that in a lot of cases, you'd have a very hard time getting somebody to relive totally in imagination. That's an awfully tall order to ask somebody to imagine in graphic detail what they went through. And we never know what they're really imagining. So in this case, like you mentioned the shared experience, the therapist can see what they're seeing, can listen to their story, and maybe some connectedness occurs that wouldn't normally occur when the person's in that world of private imagination.

In imaginal exposure as well, you often hear stories that are very cognitive. "We're driving on the road, Humvee in front, two guys died." End of story. When you're driving in the Humvee in Virtual Iraq, all of a sudden you're hearing, "well, we had, the guys in the front were part of our unit, we had stopped somewhere, we had a smoke before they hit the IED, and Joe, he was going to be going home next month, and he had a daughter he hadn't seen that was born while he was away." All this emotional outpouring that comes out. Admittedly, you can get some of that in imaginal exposure. It's the best-documented treatment in terms of efficacy for PTSD. Really, really good therapists can push a patient in imagination. But it's a heck of a lot harder. And the one thing to keep in mind is, when somebody puts those goggles on, their imagination doesn't turn off. They're still adding their own elements into the environment.

Q: But unlike a traditional video game, the object of the game here is not to experience the simulation, but to express the experience to someone else.

R: Right. Yeah. This is not a computer game. It derives from the same technology, but the goal is to live with some of the things that you experienced, not just try to win by killing as many insurgents as you can. That's not what this is about. We're trying to get people right for the real world, the civilian world. It's not about getting to the next level by killing as many of the enemy as possible. It's about processing what you experienced, the painful memories that you have of things that you had to go through in combat, ad making yourself right with those memories.

posted February 2, 2010

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