ARLINGTON, Va. (Army News Service, Jan. 25, 2011) -- In the past six years, virtual reality "games" have evolved from plain old fun into a complex exposure therapy application to help Soldiers with combat-related post traumatic stress disorder return "home" from Iraq and Afghanistan.

Dr. Albert Rizzo of the University of Southern California Institute for Creative Technologies, is a pioneer in using immersive technologies to address issues of mental health and brain injury, including virtual reality treatments for post-traumatic stress and motor rehabilitation.

He recently led a discussion about the evolving "Virtual Iraq" program within PTSD Virtual Reality on the U.S. Army's Online and Social Media Division Bloggers Roundtable.

"Although military training has better prepared Soldiers for combat in recent years, such hesitancy to seek treatment for difficulties that emerge upon return from combat, especially by those who may need it most, suggests an area of military mental healthcare that is in need of attention," Rizzo said.

In 2004, ICT partnered with other institutions, such as Cornell Medical College, Emory University and Madigan Army Medical Center at Fort Lewis, Wash., on a project funded by the Office of Naval Research to develop a series of virtual reality exposure therapy environments known as "Virtual Iraq."

The initial prototype system was constructed by recycling virtual art assets that were originally designed for the commercially successful X-Box game and U.S. Army-funded combat tactical simulation trainer, "Full Spectrum Warrior."

This first prototype, though, has continued to evolve with specifically created art and technology assets that became available to ICT in a process that was highly informed by feedback from both clinicians and servicemembers with combat experience in Iraq and Afghanistan.

"In a nutshell, we started with Full Spectrum Warrior simply as a jumpstart to begin building the application. But as we got more feedback from actual Soldiers (both in Iraq and at Fort Lewis), we evolved the application with new content that we originally created. As it stands now, there is very little of the old FSW art left in the application. Patient and clinician feedback has guided our developments of the new updated versions we are currently working on, using the game engine called Unity," Rizzo said.

But now, Virtual Iraq, and a recent version called Virtual Afghanistan, has progressed to include much more.

"You're wearing a set of goggles that have visual panels for each eye and there's also tracking devices on the headsets, so as you turn your head and physically move your body around, the graphics update within the head monitor display and you get the illusion of being immersed within the virtual environments," Rizzo said.

The patient may start off where they are riding along in a Humvee, driving through an American theme, or through the Mojave Desert with American signage. Most patients can handle that, they get used to the situation. And they begin to narrate some of their experiences.

"In addition to the visual presentation we also have fairly sophisticated audio stimuli we run through a set of subwoofers that the user's chair sits upon or they stand upon, so that the sound of the Humvee motor and bombs can be felt," Rizzo said.

"We also use a smell machine which can pump out up to eight different sets that are reminiscent of Iraq and Afghanistan -- things like gunpowder, diesel fuel, burning rubber, rotting garbage, body odor or Iraqi spices," he said, adding that smell is one of the strongest triggers of memory.

When clinicians work with Soldiers, they use a kind of "Wizard of Oz" interface to help customize the experience in ways that will best further the Soldier's treatment progress.

"The wizard is behind the curtain manipulating what's going on outside the curtain," said Rizzo. "The clinician can do that in VR. The patient can be placed in the environment, the time of day can be changed, the weather conditions, the ambient sounds, and then as they drive down the roadway, on a mouse click, the clinician can introduce new stimuli into the environment in order to pace the story in accordance to what the patient is narrating."

When the patient progresses through that initial stage, he or she will progress to a similar Humvee environment, by either driving the Humvee, riding as a passenger, or standing in the turret position.

"We can manipulate those types of variables, and we can put them on an Afghan or Iraq roadway with quite different types of scenery," Rizzo said.

"We can go from a very passive drive through an Iraqi dessert, which initially may be very anxiety provoking for a patient as they're narrating their experience, and we can go off into the fog of war, an IED explodes, a passenger in the vehicle is injured, insurgents emerge from behind some buildings and attack," Rizzo said.

The aim here, he said, is to put the patient in environments that are reminiscent of the experience that first traumatized them, and then to try to customize those environments and pace them so the patient can handle it.

As patients progress through the treatment, their recounting of their experiences becomes more detailed and more personal, Rizzo said.

"The patient may go back and say, you know, before we even left on this mission, we were having a smoke and Bill was talking about how he was going to see his kid ... and then he got in the Humvee in front of us ... and then he got killed," Rizzo said, relating an experience a Soldier may have had in the past. "That's when you start to see the emotionality come out. You see the wet eyes and the sweaty palms, but it's done in a pace that the patient can handle."

Rizzo said that's when the well-trained clinician can really help patients start to turn the corner in their recovery.

Rizzo said that one study has shown that 16 of 20 Soldiers who have competed the treatment no longer meet the criteria for PTSD. But he also said that it's not the software that is really helping Soldiers.

"The technology doesn't fix anybody," Rizzo said. "It's the therapist and the therapeutic process of exposure therapy that works the magic, so to speak."

This project has been sponsored by the ONR; Telemedicine and Advanced Technology Research Center; and U.S. Army Research, Development, and Engineering Command.