Albert “Skip” Rizzo received his Ph.D. in Clinical Psychology from the State University of New York at Binghamton. He is a Research Scientist at the University of Southern California Institute for Creative Technologies and conducts research on the design, development and evaluation of Virtual Reality systems targeting the areas of clinical assessment, treatment and rehabilitation. He agreed to be the first interviewee for our series.
Click here to read how Dr. Rizzo answered these questions:
- Dr Rizzo, you are a longtime participant in MMVR. What key advances in your research will you be presenting this year in comparison with the 2008 meeting?
- How efficiently can such a virtual environment be used in the therapy of patients with PTSD. How can olfactory stimuli be delivered in these simulations?
- Do you plan to create virtual environments focusing on other war regions as well?
- Are you experienced with “web 2.0” applications? If so, do they affect how your research is conducted? Do they affect how you interact with your patients?
- What qualities do you see as most important for a realistic/convincing/successful simulation?
- What developments do you predict will be most noteworthy in the future of the gaming/simulation industry/technology? Do you have concerns about the increasing usage/role/importance of gaming/simulation technologies in global culture? What are likely positive and negative effects on health and healthcare?
1) Dr Rizzo, you are a longtime participant in MMVR. What key advances in your research will you be presenting this year in comparison with the 2008 meeting?
At this year’s edition of MMVR, the VRPSYCH-Lab (at the USC Institute for Creative Technologies) will have four paper presentations and a poster. These projects span R&D efforts that apply Virtual Reality to clinical areas including: PTSD exposure therapy, neurocognitive assessment, game-based motor rehabilitation and our emerging work with virtual human patients for clinical training. In each of these presentations, I am happy to say that we will either present new data from human research with these applications or describe a new VR technology refinement that will make it possible for us and our colleagues to better address scientific questions in future VR research. So for example, on the PTSD front, we now have a full data set from our initial open clinical trial and emerging results from other sites using Virtual Iraq/Afghanistan. When taken together, these data indicate consistent positive outcomes across multiple test sites. On the technology development side, our VR motor rehabilitation research addressed a different challenge—that of creating a stable low cost system for tracking 3D user interaction.
This presentation will focus on our development of an inexpensive and easy to deploy webcam-based tracking system that is now good enough to support high-fidelity capture of natural motor movement for interaction within VR game-based physical therapy worlds. So in that case, the emphasis will be on the tech solution while also including some user feedback from focus groups made up of persons with disabilities who eventually will be the end users of this system as part of their home-based rehabilitation. I have always felt that the MMVR conference, with its tight knit community of “technoclinical” innovators, was an ideal forum for keeping up both with results from direct clinical outcome studies, as well as with the advances in technology that make those outcome studies possible. While clinical outcome studies are an essential part of any scientific conference, I believe that there is an equal place for presentations that describe a novel technical approach or report incremental advances in established innovative research programs that point the way to the future. If innovation was just about the outcome data, I could simply buy the conference proceedings or read a journal article. Rather, the conference format provides a deeper insight into how scientists go about addressing a research question over time and I find value in following work over the years from the various labs that consistently present at MMVR. By observing those trajectories, it helps inform the approach that our lab takes.
2) How efficiently can such a virtual environment be used in the therapy of patients with PTSD. How can olfactory stimuli be delivered in these simulations?
For PTSD exposure therapy, the outcome data from our group and from what I can glean from the VRMC lab, are very encouraging. And I believe that future outcome results will continue in that direction. From this, it appears that the technology is not the limitation anymore. VR simulations are “real enough” to provide the necessary fear/anxiety arousal needed to promote the therapeutic process of habituation. To be quite honest, it doesn’t take much for a patient with PTSD to get engaged in the Virtual Iraq simulation—their disorder essentially “primes” them to react to the virtual content in ways that folks who have never been exposed to such combat-related trauma, don’t fully apprehend. The real bottleneck is in the training of clinicians on how to properly administer VR exposure therapy in a safe and professional manner. Current VR exposure systems are simply very powerful tools that extend the skills of a well-trained clinician. The challenge is to find enough of those well-trained clinicians to provide informed care for the number of folks coming back from Iraq/Afghanistan with psychosocial difficulties! I have been particularly encouraged to see the DOD and related organizations now getting in front of this and supporting training programs to get clinicians up to speed on this approach so that the technology can now be thoughtfully applied to really make a difference for those in need. Just recently, Barbara Rothbaum, JoAnn Difede, Greg Reger and I ran a 2-Day workshop for 24 Army clinicians on how to use VR for exposure and now the Air Force is funding a series of these same workshops. The idea of training mental health clinicians on how to use state of the art VR technology for therapy is especially encouraging in that it signifies just how far this field has come since the fledgling days of the first MMVR back in latter part of the 20th Century!
Regarding the efficient therapeutic use of the Virtual Iraq system specifically, we have always viewed the clinician to be as much of a “user” as is the patient. Thus, we have focused much of our design effort on encouraging and documenting feedback from these user groups to enhance usability and usefulness. This user-centered design effort, has fed our iterative system development since we started cobbling together art assets from the Full Spectrum Warrior tactical simulation game to create the very first Virtual Iraq prototype in 2004. This user-centered step is essential for building relevant simulations in any area of Clinical VR, but is especially important for getting it right with combat trauma scenarios. There are just some things that you can’t design very well when you rely exclusively on the view from the Ivory Tower!
This sort of thinking lead to our design of the clinician’s interface—a control panel that allows the clinician, in real time, to systematically monitor what the patient experiences in the simulation and to add or take away provocative stimulus events (sounds, sights, scents and vibration) as is required for effecting the anxiety modulation necessary to achieve the therapeutic effect of habituation when conducting exposure therapy. For example, the delivery of scent into the simulation is controlled via the clinician’s interface. We use an Enviroscent system with chambers for 8 different scent vials (gunpowder, diesel, burning rubber, body odor, etc.) through which compressed air is pumped to carry the smell temporarily into the users simulation space. While we haven’t run a study with PTSD patients to compare the additive clinical efficacy of using scent vs. a no scent condition, we feel safe on theoretical grounds that this adds to the sense of presence. Since the olfactory bulb is closely linked to areas of the limbic system implicated to be involved with memory and emotion, we felt that this was a useful element to include in the total simulation package. Perhaps at some point in the future, the time will be right to run that type of “horserace” study, but for now in the absence of that data, we have chosen to trust in theory and to go with a multimodal sensory “shotgun” approach to maximize presence and engagement to promote therapeutic benefit.
3) Do you plan to create virtual environments focusing on other war regions as well?
Yes. We have recently released our first version of Virtual Afghanistan. This was accomplished by making adjustments in terrain, architecture, clothing and signage. We began that process over a year ago when it became evident that there were a growing number of U.S. service members who served in Afghanistan and that those numbers would likely continue to expand with the impending phase-out of troops in Iraq. This thematic modification will also make our content more relevant for treatment of NATO coalition troops from other countries serving in that region. We have also built an American themed desert environment based on patient feedback about the challenges that some vets face upon the return home. Finally, we have acquired feedback from some Israeli Defense Force members regarding what we need to do to tweak Virtual Iraq to create a virtual “Gaza” scenario in the near future, and that is now in the development pipeline.
4) Are you experienced with “web 2.0” applications? If so, do they affect how your research is conducted? Do they affect how you interact with your patients?
I think there is fair bit of positive potential for such distributed, avatar-based worlds like Second Life, Active Worlds, Entropia, etc., especially in areas of health education and for providing a space for support group activities, as in the Asperger’s oriented space on 2nd Life called Brigadoon. How far these digital spaces go for therapeutic aims is still an empirical question. In each case, one has to balance the needs for optimal care for a specific clinical condition with what is possible to do credibly “in-world”. I get a little nervous when I think about providing therapy to someone I have never met in person and relating to what could be an idealized avatar representation that they have chosen or constructed that may bear no resemblance to them at all. From my previous experience as a clinician, there is a lot of information in how someone communicates face to face, eye gaze, vocal intonations, body gestures, choice of apparel, etc. that is lost in this form of distance therapy. I know that there are many reasons why a telemedicine approach makes sense (costs, remote delivery of service in areas where there are none, etc.), but in lieu of some randomized controlled data on clinical efficacy and best practice guidelines, I think this is an area where we need to be cautious. I know this sounds very curmudgeonly, but I think I would prefer to use Skype with a webcam, over conducting therapy with an avatar representation of a patient. And I would never recommend anyone to do PTSD exposure therapy without being in the room physically with them. Our work has primarily had the focus on extending the skills of the clinician with VR tools and thus we haven’t focused much on Web 2.0 as a therapy format.
Now in other areas of cognitive/motor assessment and rehabilitation, I think there is a lot more potential. The challenges at this point really seem to center around 3D User Interface and Immersion limitations, but as we have seen with standalone VR approaches, those limits may be less of an issue in the future. For example, I could see the creation of motivating group activities where stimulating cognitive and motor exercises are done in groups either cooperatively of competitively online for a positive aim. Elderly persons or those with disabilities that limit functional independence outside the home, could achieve a sense of engagement with others while interacting in growth oriented activities that go beyond what one may experience sitting passively in front of the television. In essence, lots of challenges, lots of hope and a heckuva lot of good research to be done in this area!
5) What qualities do you see as most important for a realistic/convincing/successful simulation?
I think in clinical applications, the most important component is for a VR designer to know as much as possible about how good evidenced-based treatment addresses a clinical condition in the non-VR world and then make an honest appraisal as to what they can add to that with the cost and complexity of a simulation. After that part has been thought through, it is essential to have your target user group participate in early design work and include consistent follow-on testing with users to inform iterative development cycles. All the usual suspects follow after that: multisensory input, well-designed interface, responsive tracking, flexible ability to adjust software parameters, etc. Also, knowing what type of display format best addresses the clinical target is a key issue. There are some app. areas where full immersion is less relevant, like in many of the motor rehab applications where a nice wide FOV stereo screen works great. However, for all the criticisms that HMDs have been subjected to over the years, I believe they still are the best approach for some of the psychological applications where full immersion is important—and with some of the more recent systems that are available with built-in 3DOF tracking (eMagin, Vusix), they are portable, low cost and can allow a clinician to “do” VR easily in an office setting.
6) What developments do you predict will be most noteworthy in the future of the gaming/simulation industry/technology? Do you have concerns about the increasing usage/role/importance of gaming/simulation technologies in global culture? What are likely positive and negative effects on health and healthcare?
There is no doubt that the recent growth in the interactive digital game industry arena will continue to drive developments in the field of Clinical VR. The gaming industry juggernaut’s growth is evidenced by the fact that as of 2002, it had surpassed the “Hollywood” film industry in total entertainment market share, and in the USA – sales of computer games now outnumber the sale of books! And this digital “gold-rush” has driven technology and social developments well beyond early expectations. The impact of this can be readily seen in the areas of graphics techniques and horsepower, display technology and in the creation of novel interface tools, the evolution of which has been directly driven by the economic growth of the game industry. Just one example of the game industry’s impact on graphics – the original SONY PlayStation, released in 1995, rendered 300,000 polygons per second, while Sega’s Dreamcast, released in 1999 was capable of three million polygons per second. The PlayStation 2 rendered 66 million polygons per second, while the first Xbox set a new standard rendering up to 300 million polygons per second and all this has continued to increase exponentially with the latest Big Three offerings. Thus, the images on today’s $200 game consoles rival or surpass those available on the previous decade’s $200,000 computers. This is Moore’s Law in overdrive when big money and market enthusiasm is on the line!
In large part due to the economic drivers in the game industry, massive advances in graphics have pushed the field almost beyond the level where the term “graphic realism” really captures the point. By contrast, a more apt descriptor could soon be graphic unrealism! Such hyper reality can be seen in some of the latest offerings from the game development company Crytek. In their recently released version of the game Crysis, a new level of graphic expression has been reached. However, while the game industry drives the latest and greatest to feed the public craving for better entertainment options, eventually this level of software filters it way down to content available in the Clinical VR domain (c.f. Ogre).
The game industry has also driven R&D in 3D-User interfaces. For example, the Ninetendo Wii has engaged the public consciousness, driving SONY and Microsoft to take notice that humans do occasionally like to naturally interact with their game content. As well, the Wiimote interface has generated a buzz for its elegant simplicity as a 3D user interface and has been hacked for a variety of creative applications. However, a general word of caution is in order here. While a lot of groups like to bandy about terms like “Wiihab” and “Wiihabilitation”, and in fact the Wiimote has shown value as an exergaming interface, to refer to any activity afforded by an interface device as “rehabilitation” is misguided and requires a bit more thought. Rehabilitation tasks need to meet specific criteria and while it is easy to train flailing with a Wiimote, genuine motor rehab requires clear knowledge and specification of the target to be trained to inform the choice of interaction method and task design required to support precise motor action, albeit in a fun and engaging game context. Finally, while overshadowed by the excitement surrounding the Wii, the Novint Falcon force feedback system now offers a new set of options for game-based rehabilitation at a cost of less than an IPOD! We have now developed bimanual coordination games for stroke patients by yoking two of these devices together on a single laptop and some of that work will be presented at MMVR this year.
But there is another side to this question. As new media technologies become integrated into the digital homestead, questions are commonly posed as to whether people will become so involved in their activities in cyberspace (games, blogs, chatrooms and otherwise), that they will in turn neglect their social and functional involvement in the “real-world”. Some have expressed concern about persons who might prefer to spend time in Web 2.0 metaverses and form relationships with avatar representations (idealized or otherwise) that embody a person behind the screen a continent away! This example seems to strike a unique chord in everyday judgments about pathological interests. It becomes possible to quickly view these activities as a threat to psychological wellbeing by way of providing an unhealthy substitute for physical proximity and interaction with “real” humans, and this in turn could promote or exacerbate social withdrawal or other forms of psychological disturbance? Yet we can observe socially-evolved Internet communities based on shared interests that serve as meaningful personal and social outlets for many participants without ever requiring face-to-face interaction.
Even more contentious is the debate as to whether children and impressionable adults will display dysfunctional behaviors due to extensive exposure or experiential play in cyberspace! These issues have received considerable popular media press and academic attention as seen in discussions and reports on “Internet Addiction”, “World of Warcraft obsession”, “Facebook Predators”, “eHarmony marriages”, “2nd Life divorces”, etc. Since the mid-90’s there have been many academic careers built around research examining the relationship between internet use/gaming, etc. and measures of social interaction, aggression, prosocial behavior, sexual attitudes, academic grades, childhood obesity and participation in real-world activities. This literature has produced a lot of small sample size, albeit provocative, one-off studies (just skim an issue of CyberPsychology and Behavior) and a few large scale studies with contradictory results and no shortage of heated debate. This is consistent with the history of similar concerns that have always been raised whenever a new media form is embraced by the masses (film, comic books, TV, video games, Facebook, 2nd Life) or with the rapid adoption of everyday technology-based productivity/communication devices (from calculators to PDA’s to IPhones). Along the way, TV has produced its share of “couch potatoes” and “CNN junkies”, comic books became chic (i.e. graphic novels), people over 50 are still puzzled over the value of “texting”, and somehow the use of pocket calculators never actually produced a generation of children unable to do simple addition! The question as to whether a frequently engaged in activity becomes a pastime, a passion or a personal addiction warranting a DSM designation becomes a very contentious and thorny area that often times becomes rooted in a mix of relativist philosophy and personal value judgments.
While there will always be a percentage of the population that will get consumed in any type of media use to a degree that could be consensually agreed upon to be unhealthy, that assessment is still a value judgment. Whether it is a good or a bad thing that I have learned more about the history of the world from watching the History Channel, than from years sitting in history classes in school is a value judgment. Determining whether an isolated, insecure person with poor social skills who finds some connection with other people in cyberspace is further withdrawing from the “real” world or is learning to interact with others in what they perceive to be a safe environment, requires a value judgment. Consequently, no fully satisfying, comprehensive or generally agreed upon answers currently exist for these questions, yet. And, these issues are particularly challenging to address due to the rapid onset of the digital revolution. Essentially, the social sciences are still trying to figure out how much of the knowledge acquired from over a century of empirical study of humans in the “real world” can be usefully applied to predict the impact of activities in the “unreal” world of cyberspace on psychosocial health.
So as a scientist, I believe that the horse is already out of the digital barn and the best ethical thing we can do is to conduct great research on how we develop simulation technology with a focus on maximizing the good that it can do for people. I have no doubt that at some point, a socially repugnant VR simulation world will arrive and become quite popular in certain groups and generate a lot of controversy, just as digital games like the Grand Theft Auto series did awhile back (or even worse, Ethnic Cleansing; http://www.resistance.com/ethniccleansing/). But I don’t believe that you create a healthy society by limiting one’s choice of media options. Perhaps working to create a healthy society in other domains (better education opportunities, improved healthcare, electing political role-models that are honest and caring), would be a better place to focus ones energies than to blame cyberspace or an individual’s personal taste in media for the ills of the world!
I will now step down from my digital soapbox…thanks for the opportunity to address these questions in this public forum!