By Debra Kaufman

April 19, 2021

In the U.S. today, soldiers who have returned from Iraq and Afghanistan and suffer from post-traumatic stress have a chance to heal at one of more than 100 centers where they relive their traumas in a 3D virtual reality. Realistic immersion, it turns out, has a power to heal as well as—and sometimes better than—other, more traditional forms of therapy. That discovery and the centers themselves are the brainchild of Albert “Skip” Rizzo, who is also the director of medical virtual reality at the University of Southern California’s Institute for Creative Technologies.

Skip Rizzo
Skip Rizzo

For 30 years, Rizzo has both relied on and pioneered the science of rehabilitation using technology that has enabled greater and greater levels of immersion. Rizzo’s work started in 1990, when he was a clinician in brain injury rehabilitation, specializing in helping people who lost cognitive abilities due to an accident, stroke or other mishap. That year, he had his first epiphany on the road to rethinking rehabilitation modalities. “I had a 22-year-old client with a frontal lobe injury,” recalls Rizzo. “It was really hard to keep him motivated to stay on task with the activities we were using.” One day the client came to Rizzo’s office with a Nintendo Game Boy and showed off Tetris for a solid 15 minutes without losing concentration. “That was my first lightbulb,” says Rizzo. “I thought that, as a start, we could use Tetris to train attention.”

In 1993, Rizzo came across the city-building game SimCity and realized that games could be even more powerful than he first realized when working with clients with brain injuries. “This was a simulation game where the user could build cities and make judgements,” says Rizzo. “It was the ultimate executive function game, ideal for frontal lobe injuries, and a lot of my clients enjoyed it.” But nothing could have prepared Rizzo for the third flash of inspiration: hearing the early VR pioneer Jaron Lanier on NPR, describing a VR experience where users could “design” the location of kitchen objects and select a color palette. Rizzo listened in his car until the interview ended. It made him realize that a combination of functional environments and videogame mechanics could make rehab more effective.

He immediately read whatever he could find on VR which, in 1993, was at the height of its first iteration. He next relayed his insights to the head of the rehab center where he worked. She handed him a flier promoting a conference on the use of VR for persons with disabilities. Rizzo went to that conference and met a kindred spirit: Oregon Research Institute Senior Scientist Dean Inman, who was teaching very young children with motor disabilities how to use a motorized wheelchair with a VR headset. “It was inspirational,” says Rizzo. “At the time, you couldn’t build a VR solution with a Compaq Deskpro,” he says. “You needed a very expensive Silicon Graphics computer, and forget about the software programming. But I kept dwelling on the idea.” Rizzo pursued the concept with a 1994 academic paper on rehabilitation in VR environments.

An ImmersaDesk installation at Tokyo’s NTT InterCommunication Center media art gallery in 1997. Source: Davepape, public domain, via Wikimedia Commons
An ImmersaDesk installation at Tokyo’s NTT InterCommunication Center media art gallery in 1997. Source: Davepape, public domain, via Wikimedia Commons

Next, he took a big leap of faith and left his career as a professional psychologist to enter academia as a USC postdoc in the Alzheimer’s Disease Research Center, hoping it would help bring his vision to reality. He started knocking on doors at USC’s computer science department, describing his ideas about visual/spatial training. USC Information Sciences Institute professor Carl Kesselman and USC computer scientist Ulrich Neumann were intrigued. They had already built the ImmersaDesk system, which projected holographic-like stereo images that the user could see in 3D with shutter glasses, and Rizzo created a mental rotation training application with Kesselman to learn more.

Around the same time, Rizzo researched gender differences in cognitive functions, proving that immersion had the power to change how the mind works. “Women outperform men on fine motor control, landmark recognition [and] naming, and men outperform women in visual spatial skills,” explains Rizzo. He was interested in the impact of hormonal factors on cognitive functions—in this case, the ability to rotate 3D cubes in space—and built a task to test it. “In pencil-and-paper tests, men typically did better than women,” he says. “But when we replicated the task in VR, women did as well as the men.” After 140 training trials in 3D VR space, Rizzo and his team gave the paper-pencil tests again and found women’s performance was no longer significantly lower. “You weren’t predestined to be a bad mental rotator if you’re a woman. With a little hands-on interaction [in 3D space], immersion had an impact on this cognitive interaction.”

The research jump-started Rizzo’s career. “It was groundbreaking,” he says. “We were building pretty primitive computer-graphic worlds, but it was a match between what we could do effectively with the technology, measuring performance and showing the effects of training and measurement.” Galvanized by the results, Rizzo and his team built a series of visual tests to measure such things as hand-eye coordination in 3D space. When a National Science Foundation research project at USC needed a human factors psychologist, Rizzo had the luck of getting a faculty appointment in the Electrical Engineering Department that enabled him to continue his work.

A consumer version of Full Spectrum Warrior with less realistic physics than the U.S. Army’s version was commercially released. Source: Wikipedia

By the early 2000s, however, VR was regarded as a failed technology. “The hype was in the 1990s,” he explains. “I was getting some recognition for the work when there weren’t really a lot of people doing it. But I was doing it all for clinical purposes.” Rizzo continued making inroads until he came across Full Spectrum Warrior, a real-time training game for soldiers built by Pandemic Studio in conjunction with the U.S. Army University-affiliated research facility, USC’s Institute for Creative Technologies. This discovery coincided with the U.S. attack on Iraq in 2003. For Rizzo, who had already worked at the Veterans Administration to help Vietnam veterans deal with PTSD, it suggested another project — a VR simulation that could be used for exposure therapy in treatment for PTSD.

He presented his idea to ICT’s now-executive director, Randall Hill, and CTO William Swartout, who greenlit the project, then took it to Jarrell Pair, who in 1997/1998 was project manager for Virtual Vietnam, a VR simulation of Vietnam War combat to treat veterans suffering from PTSD. “Jarrell loved the idea,” says Rizzo. The two built a prototype scenario on the Gamebryo graphics platform, which ran on a laptop plugged in to a low-cost headset. Rizzo applied for multiple grants and got turned down and laughed at until the sheer numbers of returning veterans with PTSD made new treatments a pressing reality. Moving to USC’s ICT in 2004, he continued his work in rehab and the funding finally landed. Since the investment by ONR in 2005, the team has built out four different Middle East-themed war scenarios and has begun the process of running clinical tests.

By the mid 2000s, Rizzo and his team had the data they needed to prove that the Virtual Iraq/Afghanistan system produced positive results. In their first open clinical trial, they analyzed 20 active-duty soldiers who completed the treatment with the system and found “statistical and clinically meaningful” results—a more-than-50 percent decrease in PTSD symptoms. At the end, 16 of the 20 soldiers taking part in the VR experience no longer met the official criteria for PTSD. Later, 80 percent of those who completed treatment exhibited meaningful reductions in PTSD, anxiety and depression, and anecdotal evidence from patient reports suggested improvements in their everyday lives. Later studies reinforced the findings and proved that the VR training led to “improvement in psychobiological measures of startle and cortisol reactivity to a trauma-relevant scene.”

A soldier in the immersive environment of Bravemind. Photo courtesy Skip Rizzo.

In 2011, based on the early promising outcomes of the initial Virtual Iraq/Afghanistan application, the U.S. Army funded the development of an updated and expanded version. Rebuilt from the ground up using the state-of-the-art Unity game engine, the system is now referred to as Bravemind. It offers 14 VR scenarios that put the subject in different Iraqi and Afghani villages, an industrial zone, a roadway checkpoint, slums and high-end residential areas, a mountainous forward operating base and a hospital receiving area modeled after one at Bagram Airbase. In addition to these selectable virtual scenarios, Bravemind also features directional 3D audio in addition to vibrotactile and olfactory stimuli. The updates were informed by feedback from clients and clinicians who used the previous (2007) Virtual Iraq/Afghanistan system. Currently, 100 Bravemind systems are installed in Veterans Administrations, U.S. Army medical centers and university-based clinics.

Photo courtesy Skip Rizzo.
Photo courtesy Skip Rizzo.