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October 02
2017

ISSUE

Fall 2017

DR. SKIP RIZZO AND THE RISE OF MEDICAL VR THERAPY

By NAOMI GOLDMAN

Albert “Skip” Rizzo, Ph.D., Director, Medical Virtual Reality, USC Institute for Creative Technologies (All images courtesy of Dr. “Skip” Rizzo and the USC Institute for Creative Technologies)

 

Once thought to be a technology exclusively for entertainment, virtual reality applications pioneered by Albert “Skip” Rizzo, Ph.D. have provided life-changing therapeutic results for clients with serious anxiety disorders and members of the military in particular.

As the Director of Medical Virtual Reality at USC’s Institute for Creative Technologies (ICT) and Research Professor at the USC’s Department of Psychiatry and School of Gerontology, Dr. Rizzo has been at the forefront of dramatic innovations in clinical research and care for more than two decades, and his application of VR as a valuable tool in medical treatment underscores the broadening growth of VR beyond entertainment.

A leader in artificial intelligence, graphics, virtual reality and narrative, ICT advances low-cost immersive techniques and technologies to creatively address vital medical issues facing society. Under Dr. Rizzo’s direction, ICT has pushed the boundaries in treating people affected with debilitating anxiety disorders. Those treatments include landmark efforts to help military personnel with Bravemind, a virtual reality exposure therapy for treating Post-Traumatic Stress Disorder; Stress Resilience In Virtual Environments (STRIVE), which aims to better prepare military personnel for emotional challenges inherent in the combat environment, before they deploy; and SimCoach, a Web-based virtual human to assist people in care to overcome barriers.

ICT has also developed interactive “Game-Based Rehab” to augment physical rehabilitation for patients recovering from stroke or traumatic brain injury, as well as for the elderly and those with a disability.

VFX Voice talked with Dr. Rizzo about the rise of VR as a powerful therapeutic tool, the bumps in the road, and the promise that lies ahead.

Virtual Iraq/Afghanistan delivers virtual reality exposure therapy for treating PTSD.

“The lightbulb ultimately went off thanks to a young man and his Game Boy. … I was struck by kids who played video games for hours on end and imagined, what if you could get a client engaged in well-produced sophisticated con- tent to do their rehab for that period of time?” —Dr. Albert “Skip” Rizzo, Director of Medical Virtual Reality, USC Institute for Creative Technologies (ICT)

Q: What was the thought process that led you to pursue VR for use in clinical psychology and rehab?

A: The lightbulb ultimately went off thanks to a young man and his Game Boy. In the early 1990s, the state of cognitive rehab was really limited by the absence of technology. I would tell my clients that if you want to recover your brain function, your attention, memory and executive function, you would have to put in the same amount of effort into rehab exercises as if you wanted to learn to play the violin. It became more and more obvious to me that to do rehab at a level where you can really measure improvement, you have to do it for intense periods of time beyond what is pragmatically feasible with the cost of having humans facilitate that work. But armed with technology, where the user can practice on their own, you’re looking at a much greater possibility. I was struck by kids who played video games for hours on end and imagined, what if you could get a client engaged in well-produced sophisticated content to do their rehab for that period of time? Then one fateful day in 1991, I watched a less than compliant rehab client transfixed for hours by his Nintendo Game Boy and that was the ‘aha’ moment that kicked things into gear.

It started with the idea of using game-based stuff to make it fun and engaging, but as I heard of VR, I knew that the context matters and we could do it. I was naïve and had no idea about the long road ahead. Had I known how far we were from realizing that vision, I might have chickened out!

“Virtual Patients” use virtual human technology to train future clinicians in therapeutic interview skills.

Q. You’ve described the early years in the field as the ‘nuclear winter of VR.’ Tell us about your path during that era.

A: During the first challenging wave of VR, I got tossed a life buoy to make me believe there was hope. Back in 1993, Dr. Dean Inman at the Oregon Research Institute had developed a motorized wheelchair training system for children. He built something where you put the user’s own wheelchair on a set of rollers that would induce the movement of the wheels and navigate them thought a virtual obstacle course. But the key thing to motivate the kids was that after they completed a certain amount of training they could virtually fly off into the clouds in their wheelchairs wearing a head-mounted display. Their faces lit up and I was sold!

By the time I got into this academically in 1995, I had seen some inspiring things and was excited about VR’s potential. But right before I got my spot at USC I got to try a headset myself – and it was really bad. I walked around a virtual city, the interface was clunky, and I got stuck inside a very primitive building and realized this isn’t ready for prime time after all.

When I got my position at USC’s Alzheimer’s Center, it was right across the street from computer science. My strategy was to pester people to get access to equipment and programming – and that’s what happened. I saw the wreckage of the past and wanted to move forward, and as we were working on this stuff, everyone else caught on that VR wasn’t ready for the technology. Companies dissipated. VR magazines fizzled. VR conferences crashed and burned. And all of a sudden everyone was excited about the Internet and moved on as VR was labeled a failed thing. And it didn’t really hit its second life until last year.

Afghan helicopter extraction. Virtual Iraq/Afghanistan.

Q. A lot of your work has focused on supporting members of the armed services –Bravemind on the therapeutic side for veterans diagnosed with PTSD and pre-deployment combat stress management with STRIVE. What was the genesis of your emphasis on this population?

A. I always had an interest in helping veterans. I had previously worked with PTSD patients, primarily Vietnam-era veterans, during a clinical internship at the Veterans  Administration in  Long Beach back in 1985. Fast forward to 2003, I saw a video clip announcing the XBox game Full Spectrum Warrior – and it struck me just like the situation in Iraq. I was following the events of the war and thought we simply cannot have another Vietnam. We’ve got to be ready for these folks to come home and this technology is looking good enough that we can develop these kind of exposure therapy applications to be prepared. Though most people weren’t thinking that mental health and re-entry issues were going to be a problem as we were still in the ‘Mission-Accomplished’ era.

As it happens, I found out about Full Spectrum Warrior game because it was on the ICT website. ICT had received a contract from the U.S. Army and hired Pandemic Games to create it as a combat tactical simulation tool that the Army could use with the XBox for training because they had so much success with America’s Army as an online recruitment game. They wanted to go all in for training with squad tactics as you could put an interface into an XBox and it would unlock actual missions.

I went to ICT with a mission to take the art assets from the game and build it in away that allows the clinician to control the elements and put people in different locations. I paired up with Jarrell Pair who was the programmer and we pitched it to ICT and built a primitive prototype – with basically no funding – by Spring of 2004. We yanked one street out of Full Spectrum Warrior and put a person in headset running VR off of a laptop … and different keys on the keyboard would make things happen. Toggle would change the illumination in the environment from morning to afternoon to night … push a button and a bunch of guys in a jeep with guns would come pouring out of an alleyway and start firing … or an insurgent would pop up, or a helicopter would fly over. That was the root of all that came next.

Afghan humvee. Virtual Iraq/Afghanistan

Q. How does Bravemind work?

A. Bravemind is our VR exposure therapy – a means for a patient to confront and process their trauma memories through a retelling of the experience – aimed at providing relief from PTSD – and it has been shown to produce a meaningful reduction in symptoms. Rather than relying exclusively on imagining a particular scenario, a patient can experience it again in a virtual world under very safe and controlled conditions. We see that young military personnel, having grown up with digital gaming technology, may actually be more attracted to and comfortable with a VR treatment approach as an alternative to traditional ‘talk therapy.’

The current application features a series of virtual scenarios including Afghan and Iraqi cities and desert road environments and scenarios relevant to combat medics. In addition to the visual stimuli presented in the VR head-mounted display, we can deliver directional 3D audio, vibrations and smells. Clinicians control the stimulus presentation via a separate ‘Wizard of Oz’ interface, and are in full audio contact with the patient. The app has been distributed to more than 100 clinical sites and we are also developing scenarios to address military sexual trauma.

U.S. Army veteran interacts with the Bravemind VR therapy to safely relive his deployment experiences. In addition to the visual stimuli presented in the VR head- mounted display, directional 3D audio, vibrations and smells can also be delivered. (Photo credit: Stephanie Davis Kleinman French. Photo copyright © Albert “Skip” Rizzo)

Q. You’ve said ‘war sucks, but from it much flows that we can learn from.’ How have these modalities originally devel- oped for military personnel been translated for benefit to civilians?

A. We explored use of VR to help treat victims and survivors of terrorist attacks after the Paris events in 2015, but the funding has always been a barrier. Now we’re trying to do some things over in Turkey around attacks on airports, bars and mosques, which might take the shape of capturing environmental elements with a good spherical camera and doing 3D graphic overlays of the panoramic content … so we might have a second chance to develop tools to support the survivors of terror attacks.

I had proposed an idea back after the Boston Marathon bombing to put together a team of people that would donate their time as Virtual Volunteers, that whenever there was one of these attacks, local graphic artists would go and model some of the spaces. With Boston it might be the one street where the bombings took place, the interior of an ambulance and maybe a hospital setting, that’s all you need. Whereas Bravemind was a complex endeavor with 14 different worlds built to address the diverse kinds of needs of a soldier deployed there … for a constrained terrorist attack, spherical video with 3D graphic overlays is likely the answer to have the systematic control to ramp up the provocative nature of the event.

U.S. Army veteran interacts with the Bravemind VR therapy to safely relive his deployment experiences. A landmark effort to help military personnel, Bravemind has been shown to produce a meaningful reduction in symptoms of PTSD. The app has been distributed to more than 100 clinical sites.

Q. What is the outlook for funding projects like these that hold great potential for widespread application?

A. Virtual Volunteers was me as a do-gooder wanting to build a community of people to step up, but ultimately you need someone to manage and integrate the work, and that takes income. I’m trying to do everything I can to move things into the commercial sector. Academia is great for invention of new ideas and doing things no one has done before, but going from advanced research prototype to production and product level requires an economic driver. The arduous process of applying for grants and negotiating agreements gets in the way of innovation. I’d like to see some of the majors endow a center where in perpetuity there would be enough money to orchestrate these types of beneficial projects to advance the use of pro-social VR.

Capture. Bravemind allows veterans to process their trauma memories in a safe, controlled setting. Clinicians control the stimulus presentation via a separate interface, and are in full audio contact with the patient.

Q. What projects are next on the horizon at ICT?

A. We’re investigating using VR for pain It has such a solid research literature and it’s now becoming more of a commodity, because we have tools that work. We’re also looking beyond distraction to chronic pain management, which is about reaching people with the cultivation of skills they can access every day to reduce their experience of chronic pain.

We are going to move forward on some things related to addiction, to help people after they quit to essentially ‘stay quit,’ known as relapse prevention. I’m looking at putting people in high-risk virtual environments such as bars, crack houses, shooting galleries or social events where they have exposure to stimuli like everyone is drinking or smoking or doing coke. In rehab the person can’t use, so in a safe VR space you are reducing high levels of urge state in a setting where they can’t follow up and the exposure has no negative consequences. You’re behaviorally starting to break the cycle of addiction similar to what we’ve done in anxiety disorder work. We’re planning to do this in concert with a pharmaceutical approach using [Natrexalon], an opiate blocker, which suppresses the brain reinforcement schedule. So when you put an addict into a controlled VR environment and they experience an urge state, you’ve got the clinician right there to help them tap into their cognitive behavioral strategies and coping skills. The opiate epidemic is one thing, but I think we can leverage technology to reduce a wide spectrum of addictive behaviors in new ways.

And the next real big thing is to populate these environments with intelligent virtual humans that can serve a lot of roles beyond being just being boxed in a virtual environment. They can be vital tools to train doctors on clinical skills by creating virtual patients as healthcare guides and in other areas where interacting with a credible virtual human agent will have dramatic impact on improving health care.

Veteran interacts with SimCoach, a Web-based virtual human that helps overcome barriers to seeking care.

Web-based virtual humans in SimCoach help soldiers, veterans and their families overcome barriers to seeking care.

The “Virtual Interactive Training Agent” is a VR job interview practice system for building competence and reducing anxiety in young adults with Autism Spectrum Disorder.

Q. Where are the VR artists coming from – transition from the entertainment industry or more organic growth in the medical VR field?

A. There is certainly some crossover from entertainment, but also a ton of interest in our field. VR in entertainment has a lot of energy and enthusiasm, but it’s also afield with heavy competition and wreckage. Now we’re seeing people looking at the evolved scientific literature, recognizing that it’s theoretically sound and pragmatically possible and something that is getting paid a lot of attention. And health care is the second biggest market after entertainment in Goldman Sachs’ Report on VR. So maybe medical VR is the way to satisfy the creative urge to do VR, with the potential to make money and do something really good for humanity. Now that’s a compelling vision.

Albert “Skip” Rizzo, Ph.D. interacts with a veteran using the Bravemind VR exposure therapy. (Photo credit: Branimir Kvartuc)

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