Published: April 27, 2015

Albert “Skip” Rizzo

Director for Medical Virtual Reality — Institute for Creative Technologies

Research Professor — USC Davis School of Gerontology –USC Keck School of Medicine, Department of Psychiatry & Behavioral Sciences

Written by: Jennifer Christensen

Disclaimer: In an effort to retain the integrity of the blog’s format, interview questions and answers are abridged. Every effort, however, has been made to preserve the spirit and integrity of the interview.

Our spotlight series profiles Alfred “Skip” Rizzo, whose work in the design, development and evaluation of virtual reality (VR) systems in the treatment of PTSD earned the American Psychological Association’s 2010 Award for Outstanding Contributions to the Treatment of Trauma.

We asked Dr. Rizzo several questions regarding the use of virtual reality exposure therapy in the treatment of PTSD in order to provide insight into the vast potential of virtual technologies and expose the interdisciplinary and collaborative efforts that span the domains of psychological, cognitive, and motor functioning in both healthy and clinical populations.

How did you come to realize virtual environments could be effective in treating PTSD?

Technology really started to emerge in the 1990s, becoming much more practical and usable. While engaged in clinical work, I noticed how patients were much more enamored with gaming technologies than the more traditional clinical methods. It hit me how clinical practice could leverage new technology to motivate people, especially veterans coping with PTSD, to engage in a modified form of therapy.

Skip Rizzo’s cognitive work with VR addresses the use of VR applications to test and train attention, memory, visuospatial abilities and executive function. His work in the motor domain includes the development of VR game systems that address physical rehabilitation post stroke and traumatic brain injury and for prosthetic use training. He is also currently examining the use of VR applications for training emotional coping skills with the aim of preparing service members for the stresses of combat.

How has the military community embraced your efforts?

It was difficult to get the military to buy into this. We originally came up with the idea in 2003 after building a prototype off an XBOX game, Full Spectrum Warrior. A July 2004 article in the New England Journal of Medicine by Charlie Hoag that focused on the need to address PTSD with veterans returning from Iraq and Afghanistan inspired us to apply for funding. The Office of Naval Research contacted us and provided funding for our initial clinical trial in San Diego.

How do you enlist veterans’ participation?

We have advertisements, posters and referrals. The standard approach at encouraging research participation, really. There is an approval process for every clinical trial, which we were subjected to. The Institutional Review Board (IRB) has to review details of the proposed clinical trial before any research is conducted.

What is the average age of the research participant? Do you find younger veterans to be more amenable to the technically-sophisticated approach at PTSD therapy?

We have a real mix of research participants. Some of the studies that rated how people evaluated these things did not specifically investigate the age difference. However, the studies did not have large sample sizes and there might not have been enough statistical power to be able to make such an observation. That may be a factor as well.

I have minimal data to support this, but we may be drawing in more digital generation service members, who may not normally come into therapy.

Do the ethical considerations in protecting research participants in a virtual environment vary from a more traditional research environment?

We have to always be vigilant of how a patient is reacting to stimuli and remind them they can discontinue whenever they feel like, but we really do not want them to do this because we do not want to reinforce avoidance. We always have very rigorous protocols, we follow standard processes, monitor for side effects, like cyber sickness, and we do pre- and post-rating sessions. Ethically, the overarching principle in all of this is, in any of our VR applications, we typically try to look at what is an evidence-based approach to begin with and then try to do it better or take advantage of the assets VR provides that will confer an added advantage. VR exposure-therapy follows the exact protocols used in more traditional settings; we are just using VR instead of just relying on using the patient’s imagination.

I read in another interview that you acknowledge the potential of a world like SL, but feel it may not, at the moment, be the most appropriate setting for treating PTSD. What are the limitations that prevent such an environment from being conducive to your efforts? Are there any modifications/accommodations that can be applied to remedy this?

I am still old-school when it comes to treating PTSD. I am always hesitant when the therapist is disconnected in some degree from the person they are treating in a trauma-focused fashion. In SL, you are not reading cues as well. However, it does not eliminate it from being used as a potential tool. I think, in the future, it will improve. I also had proposed a SL treatment tool that could be used in group therapy. I proposed that a social gathering place be developed, like a western bar or something like that, and you walk out the back door and you see a desert out there. And what you could do is, as you continue to walk out into the desert, it becomes more and more like Iraq or Afghanistan, complete with some battle wreckage, etc. A different person in the group would then lead the whole group through a walk-a-bout, which would become more provocative as they progress, giving an individual an opportunity to tell their story. In essence, with trauma-focused exposure therapy, you encourage the patient to tell their story, to narrate and process their experience. An SL therapy session would have to be employed as part of a more comprehensive exposure-based treatment.

Trust me, I am a fan. I am not adverse to SL. I think, in essence, the future of a lot of clinical VR is going to be in shared, virtual worlds and, in some cases, with autonomous agents within those virtual worlds expanding into the real world.

Do you tailor simulations specifically for the individual seeking treatment? If so, what factors influence the design of the simulation?

Every simulation has a standard base: A patient starts in a Humvee, driving through a desert or mountainous region. From there, we have hot zones, which are used to introduce stimuli, anything from gunfire to attacking insurgents. We have the ability to add or remove stimuli at a moment’s notice. Ultimately, exposure therapy requires a patient to experience some level of anxiety in order to start feeling better.

As the VR applications mature, we are getting feedback from patients regarding the authenticity of the simulated environment, which helps in keeping the tools and application relevant and effective.

Where are these simulated sessions available? What is the success rate?

We are currently using Virtual Iraq and Virtual Afghanistan applications at approximately 30 sites around the country, including university clinics, VA hospitals, etc. There are even a couple sites in Europe.

A very preliminary clinical trial (an open trial with no control group) comprised of 20 patients from the naval medical center in San Diego revealed 16 of those patients no longer met the criteria for PTSD. It is still in the preliminary stages, but the work is amping up.

A 2013 CNN article states that “20% of suicides in the U.S., with the youngest (age 24 or younger) taking their lives at four times the rate of older veterans.” Do you have any evidence to support whether your work is helping to improve those numbers?

As important as it is to address suicide, it is a low base-rate behavior, by that I mean, we are talking about average numbers per year in the tens, from 30 to 50 to 70, maybe one year it hit 150 across all the branches and a lot of them have not even deployed…So it will be hard to measure the impact. I know a lot of patients have said that before they got this treatment, they would not have known what to do and I had suicidal ideations. But suicidal ideations are not uncommon. I do believe we are providing healthcare that is useful. I am just not able to publicly say we are affecting the suicide rate