Virtual Iraq

The Humvee bumps along the dirt road, its rough ride vibrating through my body.  The scent of body odor competes with the smell of exotic spices and garbage; I scan for insurgents and suspicious activity, and hear the sound of a helicopter droning overhead and the Muslim call to prayer. Suddenly, the Humvee in front explodes, the result of an IED, and amid the smoke and walkie-talkie static, insurgents leap into the road, firing directly at me. |

That’s a scenario that happens every day in Iraq, but I’m not in the Middle East; I’m at an office in Marina del Rey, California, wearing a wrap-around head-mounted display and holding a standard gameplay device to navigate through the scenario. In the therapeutic environment, a clinician would be guiding me through the experience, controlling the intensity and type of sensory input. 

This is cutting-edge therapy for post-traumatic stress disorder (PTSD), a range of symptoms that have plagued soldiers after every war and finally given a psychological framework in the aftermath of the Vietnam War. Stories of PTSD for soldiers returning from Iraq have already made the news, and the prospects for a torrent of PTSD cases in the future are, unfortunately, likely as the conflict rages on. According to published figures, the Iraq War is expected to generate more than $800 billion in health-care and rehabilitation costs for US veterans in coming years.

In A Clockwork Orange, the youthful criminal Alex undergoes an experimental and horrific aversion therapy to turn him away from violence. Scientists have learned a lot since then about what is called “exposure therapy,” and Virtual Iraq is at the leading edge of scientific inquiry.

Virtual Iraq is, first of all, compact and inexpensive enough to fit into a therapist’s office. The software is loaded onto two laptops, one of which is the VR screen for the patient, and the other the control panel for the therapist, both of them preferably 3ghz PCs with 2gbs of RAM and an Nvidia graphics card. A vibrating platform (to simulate riding in a Humvee) can be built for $300, and the Smell machine, a powerful memory and emotion trigger, costs approximately $1800. 

Rebuilding Iraq
The birth of what became Virtual Iraq dates back to 1996 and Virtual Vietnam, among the first of several virtual reality-based “exposure therapy” solutions. The brainchild of Dr. Larry Hodges, then at Georgia Tech University (now at the University of North Carolina, Charlotte), Dr. Ken Grapp, and Dr. Barbara Rothbaum, an Emory University professor and therapist renowned for her work in PTSD, Virtual Vietnam evolved after the trio had already created VR-type applications to overcome phobias, the first for the fear of heights and then another for the fear of flying. For Virtual Vietnam, they abandoned SGI computers in favor of PCs, to make it possible to get more systems into more therapists’ offices.

Dr. Skip Rizzo, a primary mover behind Virtual Iraq, was a protégé of Hodges at the time, and helped him build the Virtual Vietnam prototype, which featured scenarios in a helicopter and in a rice paddy. “The key question was, Does VR-based exposure therapy work, or is it a novelty?  We proved that it worked,” Rizzo explains.


The imagery used in this cutting-edge therapy is easily customizable. Presently, two broad environments exist: a rural desert setting and an urban street setting. Within each, the point of view can be altered so the patient is seeing the scenarios from whichever POV is most fitting to that soldier’s situation.

 

Rizzo was later teaching at the USC School of Gerontology, doing research into cognitive rehabilitation with people suffering from brain damage. He dipped back into virtual reality to build a virtual 3D “mental rotation” test used in brain-damage rehab. That threw him into proximity with USC’s 3D immersive group and, ultimately, drew him to the Institute for Creative Technologies (ICT), a partnership between USC and the US Army that focuses on VR and computer simulation for military training.

One of Rizzo’s colleagues from his Georgia Tech days was computer scientist J. Jarrell Pair, who was also part of Hodges’ virtual environment group. After grad school, Pair began working with Doug Trumbull’s Entertainment Design Workshop and got into the field of “wearable” computers. Rizzo eventually interested Pair in his work at USC, drawing Pair to the Virtual Iraq project.

The Virtual Iraq project, says Rizzo, has been on “a rolling start” for years through ICT. “We’ve been building immersive environments for military applications for years,” says Rizzo. “Virtual reality hasn’t been the mega-industry that we once thought it would be. But niche areas, like oil and gas exploration and military applications, have taken off. I think therapy is the surprise niche application. The hard data supports the fact that it works.”

The turning point in developing Virtual Iraq, recalls Rizzo, was the involvement of Russell Shilling at the Office of Naval Research. With his background in psychiatry and having worked on the video game America’s Army, Shilling believed in the possibilities of VR for therapeutic purposes, and got the initial money for the project.

“The Office of Naval Research allowed us to take the project out of prototype and into clinical work,” says Rizzo, who notes that the project is into its fourth year of funding.

As a prototype, Virtual Iraq relied in part on Full Spectrum Warrior, an action-war game and US Army training game developed by Pandemic, produced by ICT, and distributed by THQ. (ICT later produced Full Spectrum Command, a strategy-oriented serious game intended for higher-ranking military officers.)

“For Virtual Iraq, we took the artwork from Full Spectrum and ported it into our game engine,” explains Rizzo. “We have a FlatWorld Simulation Control Architecture (developed at USC’s ICT), which is code capable of building an interactive environment with spatially immersive displays, including a headset, a curved screen, and a CAVE. So, with this, you can create the program once and distribute it to three screens. That’s what made it possible for us to shop around the prototype.”

In the Marina del Rey studios, the ICT team could demonstrate the prototype on a large-screen display or a head-mounted display. On the road, they showed it with the head-mounted display. “There is some anecdotal evidence that a head-mounted display isn’t ideal because of the limited vision,” says Pair. “But with phobia treatment, it may be a good thing.” 

Adds Rizzo: “You want a controlled environment that can be delivered in a therapist’s office. And the eMagin Z800 3DVisor, which creates a virtual 105-inch display in front of your face and has basic tracking, is available at a low cost ($899 on Amazon). We can meet the needs of an office-based system with a solution that’s fairly compelling for patients.”

 

Building this application currently relies on two 3D artists, Matt Liewer and Brad Newman, computer scientist Anton Treskunov, and PTSD programmer Joseph Nunn. The game engine used for the application is Emergent’s Gamebryo. “It’s highly customizable, unlike the Unreal engine, which is more pre-built,” explains Liewer.

“There are a lot of people who take a first-person shooter game engine and use it for virtual-reality applications,” adds Rizzo. “But that takes away the flexibility. Gamebryo is a graphics rendering engine, not a game engine. It takes us longer to create things, but we have complete control.”

Rizzo stresses that the group is not creating a game. “It’s a customized, real-time movie, and the clinician is the director,” he says of the setup.

All the modeling and animation is done in Autodesk Maya, with Adobe Photoshop as the second major tool. The team has so far created two large-scale, flexible environments: a desert/rural setting and an urban street setting. Within either, various scenes can be established; for instance, one may show a patient riding as part of a Humvee convoy in a rural area, with a POV of the driver, passenger, or from the turret. Both scenarios can include IEDs, attacking insurgents, Black Hawk helicopters, wounded soldiers, and Iraqi citizens. “The goal is to work on more key scenarios and also to give the clinician more ability to customize the scenarios,” says Liewer.

Currently, the team is “Afghanistan-izing” the imagery, adding mountainous terrain and imagery pertinent to that location.

The Reality of War
Liewer, who has a degree in multimedia design, and Newman, who has one in interactive media, uses Iraqi posters and money, US military items such as protein bars and caffeinated chewing gum, to create authenticity to the scenarios. For reference, they also rely on a stack of DVDs, including Baghdad ER, Gunner’s Palace, and The War Tapes, the latter which are videos taken by soldiers in Iraq. 

Another huge source of reference video is the Internet and YouTube, and still photos on Flickr. Insurgent groups in the Middle East upload videos of their attacks on YouTube, as do soldiers. “There’s no shortage of footage,” says Liewer. “The trick is getting it to look the way we want. It doesn’t have to be photoreal—just enough to trigger the memories.” 

Adds Rizzo, “We’ve learned that a ‘cartoon’ or simple world is still very effective. People already come to you with powerful mental images, and simple cues can bring it back.” 

 

Audio is another important factor in making the virtual-reality environment immersive and authentic. Careful sound design relies on Hollywood sound libraries with actual recordings of gunfire, helicopters, and so on. “The sounds you hear on Virtual Iraq are real,” Rizzo says. “And we can position them in space and use the binaural headset’s tracking capabilities.”

Smells for the experience conjure up memories of the novelty Smell-o-Vision, used for a handful of movies in the past. But, for treating PTSD, scents are actually a very important component. In Virtual Iraq, the menu of odors includes burning rubber, cordite, weapons fire, Middle Eastern spices, diesel fuel, garbage, and body odor.

“There are two reasons for smell,” says Rizzo. “Our partners had worked with smell and had experience using it with virtual reality. And the second reason is that smell links directly into the limbic system, which is central to both memory and emotion.” Rizzo reports that soldiers who have experienced Virtual Iraq have requested that two additional, very different smells be added: blood and cooked lamb.

Rizzo developed the therapist’s control panel based on what he learned from building Virtual Vietnam. “Some clinicians have limited experience in using a computer,” he says. “The controller needs to be complicated, to guide many factors, but we hide a lot of the complexity so they only have to worry about a few things. They double-click on a scenario, and the rest is [fairly simple].”

The interface looks almost like a touch screen; the clinician simply clicks on a box that generates the various effects. To change the time from day to night, the clinician uses a slider.

Currently, Virtual Iraq is installed at Camp Pendleton, San Diego’s Naval Hospital, Ft. Lewis in Washington state, Emory University in Atlanta, the University of Medical Sciences in Washington, DC, Tripler Medical Center in Hawaii, and VA hospitals in Atlanta, Little Rock (Arkansas), Manhattan and Montrose (New York), and Providence (Rhode Island). Approximately half a dozen returning veterans have completed treatment with Virtual Iraq.  

Rizzo and Pair say they have received a tremendous amount of feedback from patients and clinicians, and are adding more features and tweaking others. “All the feedback we get is valuable,” says Pair. “I knew the challenge would be prioritizing it.”

The future for Virtual Iraq is, unfortunately, rosy. Rizzo reports that the “wounded-to-killed” ratio for Iraq is an astounding 16:1 (in Vietnam, it was 2.6:1), the result of tremendous strides in body armor and medical care on the battlefield. The downside, says Rizzo, is that a very large population of returning soldiers will face significant challenges with PTSD.

“There’s an interest among members of Congress to provide the best possible care for soldiers, so there’s interest in using this not just as a therapy tool, but for more information about brain function and research on who is susceptible to PTSD,” Rizzo notes. 

The future also promises more use of computers, virtual reality, and game-like technologies for post-war rehab. Rizzo reports that a “side project” is under way in which a Sims environment is used to help family members and loved ones learn what to expect from the returning soldier and how to interact without unrealistic expectations.

“Graduated exposure therapy for simple phobias is one of the best supported in terms of therapeutic efficacy,” says Rizzo. “It’s endorsed as a first-line treatment by the Veterans Administration. It’s traditionally been done with closed eyes and the imagination. But avoidance of cues is one of the most prominent symptoms of PTSD, and that’s the rationale for VR. It’s more effective than the imagination.”