Editor’s note: This is the first article in a two-part series examining the role of technology in revolutionizing treatment for mental health and disease. Read the second part here.
The ground shakes as an explosion drowns out the musical call to morning prayer in an Afghan village. The streets empty and hurried voices argue in Arabic.
“OK,” professor Albert “Skip” Rizzo’s voice cuts in. “I’m going to make all hell break loose.”
Helicopters soar through smoke billowing from the remains of a car-turned-IED. Bodies lie in the road in torn, mangled heaps. But Rizzo isn't in Afghanistan — he's sitting in the demonstration room of the University of Southern California’s Institute for Creative Technologies in Los Angeles. A black, open room segmented into different program demo areas, it more closely resembles a stage than a lab.
As a director at ICT, it’s been Rizzo’s job for the past nine years to re-create scenes from the battlefields of the Middle East in a virtual landscape. It’s one example of how some innovators are taking video game technology and using it in new ways — in this case, to help veterans make sense of traumatic experiences.
The potential to help people, Rizzo knows, is limitless. According to the U.S. Department of Veterans Affairs, seven out of every 100 people will have PTSD at some point in their lives. About 5.2 million people will have PTSD during a given year, but that’s “only a small portion” of people who will experience trauma, the department states.
“War sucks,” Rizzo said. “But it drives innovation. The good legacy of this war will be the impact it’s had on technology development and the ethical responsibility to maximize it.”
It’s less the visual surroundings that make the virtual experience realistic than it is the sounds, Rizzo says, which one team member spent a week recording in Iraq to pull scenes together: Arabic conversations. Goats and chickens milling in courtyards. The growl of armored vehicles. A baby's cry.
“That ‘waaaaa’ in the distance just pulls at the heartstrings,” Rizzo said. “Sound is a big driver of emotion. These visuals set the stage, but the sound really does it.”
The next scene is a picturesque afternoon in rural Afghanistan. Snow-capped mountains tower in the distance and a tree offers dappled shade from the exposed hillside. Coming over the rise, a mass grave yawns underfoot, its depths piled high with hooded bodies.
This scenario was built specifically from patient memory, Rizzo said.
Most soldiers who have served in the war on terror don’t want to go back — but in order to treat and overcome post-traumatic stress disorder (PTSD), many of them will have to, at least in their own minds. As part of ICT's program, soldiers put on a headset that sits over the ears and eyes and stand on a platform that emits the feeling of movement or explosions. They are transported to a virtual Middle East, moving with the help of a game controller. Through this kind of virtual reality and video game technology, ICT’s program helps soldiers deal with memories that could alter, if not destroy, their lives back home.
No one understands that better than Jonathan Warren. Now 32, Warren served in Iraq in 2006 when he and his best friend were riding in a truck that was hit by an IED. Both were doused with diesel fuel, and Warren woke up burning, bloody and leaking spinal fluid from his ears.
“I heard screaming and realized it was me,” Warren said. “That scared me.”
Warren had to watch his friend burn as he struggled to find a medic.
“All I could do was tell him to drop and roll,” Warren said.
Warren endured two more months of combat, during which he said he was “blown up four more times.”
Finally allowed to come home in 2007, Warren found ICT’s program and enrolled immediately when faced with a long wait for counseling.
“I exhausted every option. I drank to help myself sleep and calm down,” Warren said. “For me, the VR did a good job bringing me back there to confront what had happened and what my role was in it.”
Rizzo knows Warren isn’t alone and he wants the project to help as many PTSD patients as possible. The Lone Survivor Foundation says that 71 percent of female service members who have seen combat develop PTSD from rape — a population Rizzo says ICT plans to help with its next project. Designed to help victims of sexual assault in the military, Rizzo said he plans to treat the topic with “kid gloves.”
“Initially, I thought, no, we can’t do that. But after talking with people who work with sexual assault victims, I think we can do some good here,” Rizzo said. “Our goal isn’t to rub people’s faces in it. The goal is to help a person confront the things that are hard for them.”
ICT’s virtual reality adds new dimension to a process known as prolonged exposure therapy, an approach that’s been around since the 1990s but not often used, says David Yusko, director of the University of Pennsylvania’s Center for the Treatment and Study of Anxiety.
“The vast majority of people don’t know about it and don’t use it,” Yusko said. “But it’s highly effective for PTSD, whereas medication is not very effective and talk therapy doesn’t always do enough.”
The treatment is used for PTSD caused by any traumatic event, from a car wreck to sexual assault. Because PTSD creates patterns of isolation and avoidance in its victims, exposure therapy features an approach that includes revisiting and engaging with traumatic events through memory, with the help of a clinician. Yusko said exposure therapy helps give the brain context for the event, making it more manageable.
“When you go to a restaurant, you have an idea of what’s going to happen. When you’re not at a restaurant, the information gets put away,” Yusko said. “With trauma, the brain doesn’t know what to do with the information and there’s no place to file it away. So people keep getting exposed to it. What we’re trying to do is help the brain by putting the events into context so they can be dealt with.”
Of course, it’s not always easy to tell what’s going on. Warren said his PTSD presented as panic attacks and an overwhelming sense of anxiety that he didn’t immediately realize he needed help for.
“Within two weeks of being home, I knew I wasn’t the same kid I was when I left,” Warren said. “I just felt anxious and guilty. There’s a change that goes on in the brain that makes it very hard to feel what you know.”
That's why exposure therapy works, Yusko said — it gives the brain control over the memories again.
“Exposure therapy creates a narrative so people have a context for the story,” Yusko said. “It’s kind of like seeing a horror movie: By the 10th or 20th time, it’s still scary, but it’s not as activating. But if you’re just seeing that one scary scene over and over and you don’t know why, it’s frightening.”
Warren said exposure therapy helped him control his fear.
“It gave me a new dialogue to have in my head about what happened. The first time, I cried like a baby,” Warren said. “It helped me forgive myself.”
While ICT’s program is groundbreaking, Rizzo said it’s not meant to replace a skilled therapist.
“This in an extension of treatment. We activate people’s most difficult memories and emotions with these systems in a very sophisticated, controlled and thoughtful manner,” Rizzo said. “But it’s hard medicine for a hard problem nonetheless.”
Rizzo anticipates future digital-centric generations will expect advanced technology from medicine.
“Half of the equation is treatment. The other half is making it attractive so people will seek it out. Like it or not, we’re living in a digital age and if we really care, we have to take a shot at this and see where it makes a difference,” Rizzo said. “Advanced tech like virtual reality is going to be embedded in our lifestyle to where if you’re not leveraging it, you’re going to be remiss.”
Common technology, unique applications
ICT’s work with video game technology doesn’t end with soldiers trying to get their lives back. The applications, as Rizzo and his team are learning, are endless, and one concern the programs hope to address is access to care.
Take Ellie, a virtual human being developed at ICT by researchers like Stefan Scherer and Angela Nazarian. Ellie operates within a program called SimSensei, which uses a webcam and Xbox Kinect infrared sensors to read movement and identify nonverbal cues on a user's face. As Ellie talks with a user, the Kinect tracks cues like user eye movement and smile intensity to gain information about the user's emotional state.
Nonverbal behaviors help psychiatrists glean information patients may be unable to put into words. A 2010 study of these behaviors from Wright State University found that about 60 percent of interpersonal communication is relayed nonverbally, yet clinical settings rely on spoken exchanges.
By asking a series of questions and monitoring nonverbal reactions, Ellie can infer things about a patient that take more time for doctors to identify.
Scherer hopes SimSensei will one day hasten access to care with kiosks at places like VA hospitals or any place where people can get help when suicidal or homicidal thoughts occur. Early trials also suggest that people have no problem opening up to a computer like Ellie.
“People came in and were able to talk to Ellie in such a natural way, and it surprised us that Ellie was able to hold a conversation like that,” Scherer said. “Everybody loved her and could see the immediate benefit of just talking to her.”
Of course, that’s just one of Ellie’s possible applications. Scherer said Ellie could also be useful with telemedicine or remote education, and she is even being experimented with to help autistic adults deal with difficult social situations like job interviews.
Another project that could improve access to care is called Games for Rehab, a program that uses Kinect technology to create individual, accurate physical and cognitive therapy. Using different games, patients can achieve their physical therapy goals with Kinect technology that is calibrated to their individual bodies and abilities — a step up from traditional instructions, says project manager Kevin Feeley.
“Typically, physical therapy patients are given a piece of paper that says something like, lift these soup cans. That’s kind of like the dentist and flossing. And if you do it wrong, you won’t know until you go back,” Feely said. “This is more fun and it verifies that it’s being done.”
The fewer barriers to care the better, Warren said, since the stakes for patients — whether physically or mentally injured — are high.
“If you have PTSD, you risk not getting a job, not having a gun, a lot of freedoms guys who come back would like to go on enjoying,” Warren said. “There’s not a lot out there that’s fixing people.”
Projects like these, Rizzo says, will improve the kind of care patients get and give them unprecedented access.
“Stress-related disorders are different from something like cancer. There’s stigma there. Until you break down those barriers to care, we need to create things that will attract people to novel ways of healing,” Rizzo said. “This is how we can make dramatic differences for people. In the future, if they go to a doctor’s office, this stuff is going to matter.”