education about hallucinations using an internet virtual reality

Using Technology to Teach Clinical Care

534 http://ap.psychiatryonline.org Academic Psychiatry, 30:6, November-December 2006

Education About Hallucinations Using anInternet Virtual Reality System:

A Qualitative Survey

Peter M. Yellowlees, M.B.B.S., M.D., James N. Cook, M.D., M.S.

Received January 5, 2006; revised April 4, 2006; accepted May 1,2006. Drs. Yellowlees and Cook are affiliated with the Departmentof Psychiatry, University of California, Davis, Sacramento, California.Address correspondence to Dr. Yellowlees, 2300 Stockton Boulevard,Sacramento, CA 95817; [email protected] (e-mail).

Copyright � 2006 Academic Psychiatry

Objective: The authors evaluate an Internet virtual reality tech-nology as an education tool about the hallucinations of psycho-sis.

Method: This is a pilot project using Second Life, an Internet-based virtual reality system, in which a virtual reality environ-ment was constructed to simulate the auditory and visual hal-lucinations of two patients with schizophrenia. Eight hundredsixty-three self-referred users took a self-guided tour.

Results: Five hundred seventy-nine (69%) of the users whotoured the environment completed a survey. Of the survey re-sponders, 440 (76%) thought the environment improved theirunderstanding of auditory hallucinations, 69% thought it im-proved their understanding of visual hallucinations, and 82%said they would recommend the environment to a friend.

Conclusions: Computer simulations of the perceptual phenom-ena of psychiatric illness are feasible with existing personal com-puter technology. Integration of the evaluation survey into theenvironment itself was possible. The use of Internet-connectedgraphics environments holds promise for public education aboutmental illness.

Academic Psychiatry 2006; 30:534–539

Virtual reality techniques, involving three-dimensionalimaging and surround sound, are increasingly being

used in health care education and research (1,2). Virtualreality has been used to provide medical education abouthealth care responses to emergencies, such as earthquakes,plane crashes, and fires; to treat phobias, such as the fearsof heights, flying, and spiders; and to treat posttraumaticstress disorder (3,4). Virtual reality has been used to sim-ulate the effects of stroke to facilitate a greater under-standing and empathy in caregivers (5). Virtual reality hasalso been investigated for post-brain injury rehabilitation,with treatment occurring in the patient’s home (6,7), forvirtual psychiatric treatment (8) and for pain control (9).Integration of virtual reality, simulation and modeling intoeducational curricula has been identified as a goal by arecent large survey of information technology use by stu-dents (10).

Schizophrenia is a severe mental illness with a lifetimeprevalence of approximately 1%. Most patients withschizophrenia experience auditory hallucinations, particu-larly hearing voices, and approximately one-quarter of pa-tients experience visual hallucinations (11). A commoncause of frustration and alienation for sufferers of schizo-phrenia is that their therapists, family members, and care-givers cannot really understand their experiences.

In previous work, Dr. Yellowlees has been involved increating room-sized virtual reality environments to simu-late the experience of psychosis. That project began in2001 and has been described in detail elsewhere (12, 13).In brief, patients with stable, well-treated schizophreniawere extensively interviewed about their hallucinations.Programmers and artists were employed to create a virtualpsychiatric ward and to create simulations of the auditoryand visual hallucinations using a visualization laboratorydriven by an SGI Onyx computer. This construction pro-cess took two full-time programmers approximately 4months to create the custom software required, and the

YELLOWLEES AND COOK

Academic Psychiatry, 30:6, November-December 2006 http://ap.psychiatryonline.org 535

modeling of three sets of patient experiences took about 2years in total. The final three-dimensional product was aneffective recreation of the hallucinatory phenomena butcould only be experienced within the expensive visualiza-tion laboratory and was therefore relatively inaccessible topotential students.

Janssen Pharmaceutica, manufacturer of risperidone,has also created several versions of a virtual reality hallu-cinations environment. Their system, which has beenshown at conferences and described in the popular press,uses a custom software environment that runs on a laptopcomputer with stereo display goggles (14).

We were interested in assessing whether we could de-liver a virtual psychotic environment over the Internet inorder to increase its educational reach. We also wanted tosee if personal computer graphics systems could reproducehallucinations sufficiently well that users would feel theylearned something from the experience.

Method

TechnologyWe built a virtual educational environment in the form

of a hospital ward using the commercial virtual world sys-tem Second Life (Linden Lab, San Francisco, Calif.). Sec-ond Life is a three-dimensional online computer simula-tion of the real world. Other examples of virtual worldsinclude There.com and ActiveWorlds (15,16). Users ofSecond Life download a 20-megabyte client program di-rectly from the developer which allows them to create theirown avatar (or “virtual person”) and move around theworld. They can chat with other users, play simple games,build buildings, design clothing, buy and sell items createdby other users, design their own three-dimensional objects,and write programs to imbue their objects with behavior.Approximately 100,000 people have accounts in SecondLife, and over 10,000 individuals log in every day. Over1,000,000 unique objects have been created in the system.For our purposes, Second Life provided a simple three-dimensional construction environment, as well as a way todistribute educational content over the Internet.

We took photographs of an inpatient ward and hospitalfurnishings at the University of California, Davis, MedicalCenter and created a virtual inpatient ward in the SecondLife system. We then constructed simulations of auditoryand visual hallucinations from recorded audio samples anddigital images based directly on the interview transcriptsfrom the schizophrenia patients. Some anonymous de-

scriptions of auditory and visual hallucinations that hadbeen collected in earlier studies (12,13) were also reusedwith the consent of previous research collaborators. Weinserted the hallucinations as individual objects through-out the virtual ward so that they appeared automatically,triggered by an avatar’s presence as the avatar toured theenvironment. The hallucinations included:

• Multiple voices, occasionally overlapping, criticizingthe user

• A poster that would change its text to obscenities• A newspaper where the word “death” would stand

out of a headline• A floor that would fall away, leaving the user walking

on stepping stones above a bank of clouds• Books on bookshelves with titles related to fascism• A TV that would play a political speech, then criti-

cize the user and encourage suicide• A gun which would appear under a cone of light and

pulse, with associated voices telling the user to take thegun and commit suicide

• A mirror in which a person’s reflection would appearto die, becoming gaunt with bleeding eyes

Examples of the virtual hospital ward and the halluci-nations are shown in Figure 1.

The tour began with the participant taking a virtual“badge” that provided the audio track. This allowed us tocount the number of users who toured the environment.The virtual clinic created in Second Life and viewed on astandard personal computer provided equivalent or im-proved graphics and sound fidelity compared to the versiondisplayed in a supercomputer data visualization facility in2001. The off-the-shelf construction environment enabledmuch more rapid development with the entire environ-ment, including creating the hallucinations, built in lessthan a month.

SurveyA survey collection system was placed at the end of the

ward. This allowed users to respond to questions imme-diately after their tour and while they were still inside theenvironment by simply clicking on the response of theirchoice. Their answers were automatically e-mailed to usand downloaded directly to a spreadsheet for analysis. Weused a Likert-like scale from 1 to 5 for the subjective ques-tions described in Appendix 1, with responses “StrongNo,” “No,” “Maybe,” “Yes,” and “Strong Yes.” To simplifythe online survey object, ages were presented in ranges�18, 18–25, 25–35, 35–45, and �45. Salaries were pre-sented in US$ as �$30,000, $30–$60,000, $60–$90,000,�$90,000. A survey response was considered valid

HALLUCINATIONS IN A VIRTUAL REALITY SYSTEM


FIGURE 1. Inside the Virtual Reality Program

(Top left) The outside of the virtual hospital ward building. (Top right) Inside one of the hospital ward rooms. (Bottom left) Clinic hallway showingstepping stones over abyss. (Bottom right) Survey collection at the end of the tour.

if at least seven of the nine questions were answered. Incases where a user submitted more than one survey, onlythe first submission was analyzed.

RecruitmentSurvey-takers were recruited from the general Second

Life population. Because Second Life requires a computerwith three-dimensional graphics capability and a broad-band Internet connection, we knew our population wouldnot be representative of the general United States popu-lation. In particular, Second Life users are younger, moreeducated and more likely to be male than the generalpopulation (R. Harper, personal communication). How-ever, for the first formal feedback on the project, such aconvenience sample was felt to be appropriate.

Second Life users were offered L$100 (Linden dollars)for completing a valid survey. Linden dollars are a form ofcurrency within the Second Life virtual world system, andat the time of the study L$100 was worth approximatelyUS$0.75 on the virtual-world to real-world currency ex-change (17).

An online journalist took an interest in our project andwrote an article about it which was posted in the officialSecond Life blog several days after the environment wasmade public (18). The piece was referenced by severalother popular blogs over the next week (19, 20). Based onnarrative comments from users, some survey-takers signedup for Second Life for the sole purpose of experiencingthe virtual psychotic environment. The UC Davis Institu-tional Review Board granted permission for this study.

YELLOWLEES AND COOK


Results

Over a period of 2 months, the virtual psychosis envi-ronment was toured 836 times with 579 (69%) valid surveyresponses received. The demographics of the survey re-sponders closely mirrored the demographics of the SecondLife system at large. Most responders were men (N�366,63%), but this represented a more balanced gender distri-bution than other online communities. The most commonage range was 25 to 35 years old (N�186, 32%) followedby 18 to 25 years old (N�182, 31%). Most respondersworked outside the home (N�316, 55%) or were students(N�113, 20%). Most responders earned less thanUS$30,000 per year (N�203, 35%) or US$30,000 to$60,000 per year (N�170, 29%). The results of the edu-cationally focused questions are presented in Appendix 1.

Subpopulations were analyzed for differences using two-tailed t tests. No significant differences were found whenreplies were analyzed by gender, occupation, or incomegroup.

Although the survey object in this first version had noformal mechanism for narrative comments or feedbackfrom users, many spontaneously sent comments to us.Some of their comments are recorded in Appendix 2.

Discussion

Using modern visualization technology, we have createdan Internet accessible three-dimensional simulation of thehallucinations of psychosis. Users of the environment feltit improved their understanding of the experience of hal-lucinations.

As a pilot project, this study has several important lim-itations. First, the population surveyed is a significantly bi-ased convenience sample. Existing users of an online vir-tual world system are not a representative sample of thegeneral population. Second, there was no pre-test given,so we cannot prove that participants improved their knowl-edge. We relied on the participants’ own perceptions ofeducational value. Finally, the environment focuses onlyon the hallucinations of patients with schizophrenia. Usersmight therefore give inappropriate weight to these symp-toms of the disease, rather than having a more balancedview incorporating other symptoms, such as delusions, dis-ordered speech and behavior, and negative symptoms.

In spite of these limitations, we feel this approach todescribing phenomenology is exciting. We are using thevirtual reality scenario as a teaching tool in our medical

school program and will perform a more formal evaluationof its effectiveness in teaching students about the lived na-ture of psychotic symptoms compared to traditional teach-ing approaches. We also intend to use this model as aneducational tool for caregivers attending an early interven-tion program for patients experiencing a first episode ofpsychosis.

We feel that commercial virtual world systems offer sig-nificant advantages for the development of educational en-vironments. Compared with custom software develop-ment, using an existing software system cut developmenttime for the most recent version of the psychosis environ-ment by a factor of 10. While some of this may be attrib-uted to experience gained with the previous iteration ofthe project, we feel a large part of the improvement wasdue to the tools.

In addition, because Second Life can be accessed byanyone with a Windows or Macintosh computer and abroadband Internet connection, a substantial number ofpeople can experience an educational three-dimensionalgraphics environment. Interested readers can find instruc-tions on creating a Second Life account and accessing thevirtual hallucinations environment on our Web site atwww.ucdmc.ucdavis.edu/ais.

The direct collection of survey data from within thethree-dimensional environment is novel and has implica-tions for other educational environments. Though we onlyattempted a simple survey, this type of assessment processcould be further developed to allow online students to an-swer examination questions within a three-dimensional en-vironment. It would be straightforward, for example, forus to develop specific questions for students about aspectsof abnormal phenomena in the environment we have al-ready developed, and thereby create a combined virtualeducational and assessment process that could be used ina wide variety of other educational areas. It is possible thatvirtual reality may well become an integral part of medicalpractice and training as is suggested by a number of otherstudies in the disciplines of Obstetrics (21), Neurology(22), and Family Practice (23).

Conclusions

It is difficult to teach about the internal phenomena ofmental illness, such as hallucinations, using traditionaleducational methods. In the past, virtual reality systemshave been used to create simulations of these phenomenafor educational purposes, but these systems have generallyused custom computer hardware that has limited their

HALLUCINATIONS IN A VIRTUAL REALITY SYSTEM


APPENDIX 2. Comments Sent Spontaneously to the Authors by Survey Takers

User Comments

Male 1 I wanted to say ‘‘thank you’’ for the schizophrenia simulator. It’s . . . creepy.It’s a very good thing to have available.Male 2 That tour was amazing. I didn’t think it would affect me, but about halfway through I wanted to shout ‘‘Stop it!’’Male 3 That’s freaky. The scary bit is that I could identify . . . I was diagnosed borderline.Male 4 As one who has schizophrenic friends, one who did kill himself, I was very glad to take your tour. Thank you for

providing a unique source for information.Female 1 My first husband was schizophrenic! I have experienced visual hallucinations and they are disturbing enough.Female 2 I had [hallucinations] when I had surgery from the meds. Unbelievable.Female 3 As a student studying child development and exceptionalities, I thank you for your simulation. It is very raw and

unsettling. Thank you for making more people aware of this.

APPENDIX 1. Survey Responses for the Virtual Hallucinations Tour (N�579)

Number (Percent)Strong Yes or Yes Mean (SD)

Did this tour improve your understanding of auditory hallucinations? 440 (76) 3.88 (0.86)Did it improve your understanding of visual hallucinations? 400 (69) 3.71 (0.91)Did it improve your understanding of schizophrenia? 425 (73) 3.81 (0.90)Was this experience disturbing to you? 276 (48) 3.19 (1.18)Would you recommend this tour to others? 476 (82) 4.06 (0.86)

educational reach. This project has demonstrated that anInternet-based virtual reality system for personal comput-ers can be used to create simulations of hallucinations andthat it is possible to integrate evaluation tools into a virtualreality environment. Furthermore, users of the Internet-based simulation felt that it improved their understandingof the experience of hallucinations. More comprehensivestudies of this approach to online education are warranted.

We would like to thank the team led by Professor Kevin Burrageat the University of Queensland for their work on the original versionof this project, and Dr. Jasmine Banks for the assistance of migratingit to the Second Life environment.

We would also like to thank the members of the Second Lifecommunity who gave feedback on the initial versions of the environ-ment and participated in the survey.

Dr. Cook is a paid consultant to Linden Lab and owns stock inthe company.

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education about hallucinations using an internet virtual reality

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