What got you interested in VR as a treatment tool?

Skip Rizzo (SR): What happened is that in the early 1990’s I saw the potential for VR technology to be used for cognitive rehabilitation — the kind of strategies that are needed to help people following a brain injury to recover attention, memory, multitasking abilities, and language skills. By doing these kinds of real intensive drill and practice activities, people can recover some of their function after a stroke or car accident. But the technology was very limited in the 80’s and 90’s and we were primarily using workbook exercises and paper and pencil activities. It was just very hard to engage my patients in the intensive work needed to recover brain function and foster neuro-plasticity.

Then one day, one of my clients came in and goes, “Skip, look at this. It’s a new thing; it’s a Game Boy.” I watched him, and it was like probably 1991-’92, whenever those things came out. And I remember watching him — and — this was a client who had a frontal lobe injury which affected his motivation and his ability to maintain attention. But here he was, glued to this Game Boy. I couldn’t get him to focus for more than 10 minutes on any one rehab task before, and here he was for 20 minutes on this Game Boy just going nuts and becoming a Tetris warlord in the process, suggesting that with repeated practice he got better at the task.

“Skip, look at this. It’s a new thing; it’s a Game Boy … And that was the first light bulb that went off”

And that was the first light bulb that went off, that If we can put rehab activities in a game-like context, like Tetris, maybe we can motivate activity and do rehab better.

Then I heard about virtual reality. I saw that VR was going into its first heyday, if you will. Jaron Lanier was a prominent influence at the time and he was promoting the idea of virtual reality and it was the same kind of excitement that we have today — but it took place in the early 1990s. Everybody was VR crazy and it was gonna change the world.

“And that was the first light bulb that went off, that If we can put rehab in a game like Tetris, maybe we can do things better. Then I heard about virtual reality.”

However, the reality then was that the technology just wasn’t there to deliver on that vision. VR talked a good game, but when you put on a head mounted display (HMD) from that era and saw the very primitive graphics with poor resolution, limited field of view, and the lag in visual latency of the head and body movement, it simply wasn’t capable of really delivering on the vision of creating a new way of doing rehabilitation, unlike today.

Fast forward from 1995 to the current day — the technology has caught up with the vision and we have all the enabling technologies that allow for us to create compelling VR user experiences. At the same time we have moved forward and gotten to the point where we have great graphic capabilities. We’ve got super-fast computers at a low cost. We’ve got display technology now, head mounted display technology really driven by the reality of the mass production of cell phone displays.

So let’s go back now to 1995. The vision in my particular area of mental health and rehab was that we could motivate people by introducing game elements into simulated VR environments and make it so that the very boring but important work of rehabilitation becomes fun and engaging; and it becomes functionally relevant because they’re doing it within the context of the real world they have to actually perform in.

With all this, we systematically manipulate what goes on in these worlds at a rate or pace that the patient can handle and measure their performance in a very sophisticated fashion. We could envision building a VR system that puts patients in environments that are relevant for what their challenges are in the real world. And within those environments, we could systematically manipulate the stimuli to help people with phobias to approach things that they feared in the real world and reduce those fears. Conversely, we could use VR to distract people from painful medical procedures and acute pain by putting them in engaging game-based simulations.

Back then, because VR was so bad, it was a really hard sell to make, but the theory was there and the vision was sound.

And so in 1995 I decided to make the move and I took a post-doc position at USC just so I could make friends with computer scientists that had the equipment needed to produce VR environments and so on. My office was right across the street from computer science. That’s what made it easy for me. And what I did was I started knocking on doors. I’d pitched a few ideas to computer scientists and then one day this guy Ulrich Neumann recognized the potential for the idea and he said, “I know somebody with some equipment and we can get you some programming time and we can start building and embark on a research program to begin studying this application area.”

And that was the beginning, in 1996. It took me about 4 months, but what happened unfortunately is that 1995–96 was also the start of the virtual reality “nuclear winter”. The public enchantment with VR ended because the technology just wasn’t there to deliver compelling experiences and everyone got all excited about this new thing called the World Wide Web. That was the time people started getting personal computers and email and listservs and Netscape and all that stuff, and everybody’s attention was focused in that area.

But the clinical VR vision was sound and with equipment and programming through the Computer Science Department at USC, we started building things at a level where we could use 3D projection to do visuospatial training and measurement. We also did some early head mounted display applications to test children with attention deficit disorder, putting them in a virtual classroom and measuring how well they could attend while we systematically manipulated distractions. It was during that period, from the late ’90s into the early 2000s, that the technology started to get better. I think it was around 1999/2000 that we no longer needed a Silicon Graphics “Reality Engine” ($200,000 computer) to render the graphics. We could do it on a regular PC.

The Bravemind PTSD Treatment Simulator

I Call it Clinical VR

Clinical VR, one of the names I call it, is probably one of the most scientifically studied application areas of VR, in part because in the mid ’90s, in spite of the technology limitations, people got excited about it. They wanted to build this stuff. They wanted to change the future of mental health and rehab by using the best technology available, even if it wasn’t ready yet.

And so in the last 20 years, this scientific literature has evolved to where we can state with confidence certain findings, one of which is that VR exposure therapy is effective for treating phobias, and now for PTSD. It is as good, if not better in many cases, than the traditional imagination therapy alone.

Another very powerful use for VR is its use to distract people from acute, painful medical procedures. Those findings have been replicated time and time again using VR headsets. Initial results documenting effectiveness were seen in Hunter Hoffman’s work with people getting daily wound care for significant burns or doing physical therapy after a skin graft and now the field has grown applying VR for other types of acute (and now chronic) pain In the area of rehabilitation, encouraging findings have also emerged showing that if you build a compelling game-based VR environment to deliver physical or cognitive rehab training tasks, users report enjoying the activity, they do it with more focus, and they show positive gains.

So this literature began pointing in the right direction, even in the late 90’s, and even though a lot of it was technically challenged due to the limitations in equipment and software.

An opportunity emerged for me in 2003 with the opportunity to develop VR tools for delivering exposure therapy for PTSD. People had tried it before, my colleague Barbara Rothbaum had built a very primitive virtual Vietnam scenario and showed some positive clinical gains but couldn’t get the funding to build it at a level that would get it out to all the VA sites. But the initial data was there. My other colleague JoAnn Difede in New York worked with Hunter Hoffman and built a World Trade Center PTSD exposure therapy system, and over the last few years has published a number of studies showing positive clinical gains.

So I worked with all those folks and Jarrell Pair in 2004 building our first prototype of what we called Virtual Iraq. We didn’t have any funding so we basically ripped a street out of the Xbox game Full Spectrum Warrior and pilot tested it with non-PTSD service members to see how they would react to the content available to us at the time. Then we finally got funded in 2005 and built our first clinical system and the first study followed that showing positive clinical results. So that meant I had to change positions, moving to the USC Institute for Creative Technologies in 2004 to really advance that work, but it opened up a whole new ball game for me. At that time I was still on the USC campus working at the Integrated Media Systems Center, but the move to ICT was great as they had a military focus since ICT is an Army-supported university affiliated research center.

After a lot of clinical work with veterans of the Iraq and Aghanistan wars indicating positive outcomes, we eventually got funded in 2011 to really rebuild everything on Unity (you can read a past interview about Unity here), and that has led to what we have now which is called Bravemind, going from 4 different scenarios to 14 and now addressing military sexual trauma.