The latest virtual reality (VR) technology can produce worlds so absorbing, you could almost believe you were there. For many people who experience psychosis however, their sometimes fantastical and frequently distressing worlds cannot be switched off at the touch of a button. Psychosis typically includes hallucinations ('hearing voices' is not uncommon), distortions of perception and meaning, and the scattering of thought and behaviour into fragmented or eccentric threads. Excited by the increasingly realistic environments available to the would-be creator of VR worlds, researchers have recently begun to make the conceptual leap, from trying to simulate reality, to simulating the unreality of psychosis.
One such project is the brainchild of psychiatrist Peter Yellowlees and computer scientist Jasmine Banks. Aiming to produce an interactive learning environment for students of psychology and psychiatry, they worked closely with Sandy, a patient who experienced intense psychotic episodes. Using descriptions of her experiences, work began on creating a prototype environment, including a simulation of the intrusive hallucinations that were described to the research team. These included a cacophony of abusive and derogatory voices, the experience of receiving threatening messages from the newspaper and radio, and even an image of the Virgin Mary, who transformed from a comforting vision to a vindictive and insulting apparition without warning.
Despite the limitations of using computer software to simulate what is often a complex experience, Sandy was generally positive when she saw the finished version, recounting to the researchers that the simulation was a good approximation that captured the essence of her own psychotic episodes. So accurate in places, that having her hallucinations available to others caused an initial pang of anxiety: "This is such private stuff in a way", she remarked, "your hallucinations are things only you see; no one else sees them. It's exposing a part of me that no one else has ever seen before".
However, Banks' and Yellowlees VR simulation was written for the high power computers and wall to wall screens of the University of Queensland's Advanced Visualisation and Computing Laboratory. As it was intended as a public education tool, it became clear that their project would need to run on nothing more than a desktop PC if it was to move beyond the confines of academia.
By this time, Yellowlees had moved to California to continue his work at the University of California, Davis and by chance met James Cook, an employee of Linden Lab. Linden Lab had designed and created Second Life, an online community designed partly as an updated version of the text-based MOOs, a form of interactive adventure game popular during the internet's early years. Like many of the MOOs of times past, Second Life is designed mostly for social activity and gives users significant leeway in building their own corner of an online world for others to enjoy. Unlike a MOO, Second Life is represented as a 3D graphical environment that takes advantage of the latest developments in desktop hardware to produce a feature-rich multimedia experience. Cook, a qualified doctor, joined Linden Lab after becoming jaded with the relentless pace of primary care medicine, and became intrigued about the possibilities of using Second Life as a platform to bring Yellowlees' psychosis-simulation project to a wider audience.
Although technically accomplished, Second Life was not designed to be a graphically realistic representation of reality and the building tools are designed for flights of fancy rather than serious medical simulation. Despite these challenges, Cook set about creating Second Life's first psychiatric ward, where visitors could experience what it might be like for someone experiencing acute psychosis. "I built most of the objects myself and I'm not much of an artist" Cook admits. Despite this, exploring Cook's psychotic corner of the Second Life world can be an unsettling experience. While wandering the corridors, the casual explorer is assaulted by derogatory voices ("You're nothing. Kill yourself. Do it now"). Pictures and reflections warp and change as you examine them, and the seemingly-solid changes unpredictably. In one instance the floor falls away to reveal nothing but sky below, and in another a spotlighted handgun appears menacingly on a table.
Disquieting it may be, but some might ask how accurately virtual reality can simulate such a convoluted and confusing state-of-mind. Both Jo and Abbey have experienced psychosis and both have an interest in this developing field.
As a freelance programmer, Jo has worked on a number of notable free-software and commercial projects. During a time of intense activity her mind began racing with thoughts and revelations that initially seemed beautiful and significant, but eventually turned into an intense paranoid psychosis. Although intrigued by VR projects like James Cook's, she remains a little sceptical about how successfully it could represent an experience like her own. "What seems problematic", she says, "is the experience [of psychosis] has a deeply subjective content which I don't think VR would be able to replicate without access to my subconscious. Perhaps it is evasive to say that this is not communicable to anyone who hasn't experienced the same thing, but perhaps it is not communicable at all". "It does seem to risk reducing the whole thing to a novelty", she worries, although she is not totally dismissive and sees promise in being able to relate visual sensations like the "hyper-patternedness" she experienced, or the "snatches of familiar voices muttering things I'm not conscious of thinking".
Abbey (not her real name) experienced a similarly unusual version of reality during a severe bout of clinical depression. Now a research psychologist studying mental illness, she has a particular interest in novel ways of understanding psychosis. She feels that her own hallucinatory experiences could be accurately portrayed by virtual reality, but like Jo, thinks some of the core features would be poorly represented. "During the early stages", she remembers, "I had an intense feeling of perplexity. I knew something strange was happening, but I could not work out what, and later, during the intense psychosis, I was often unaware that my beliefs and perceptions were unrealistic". Although she thinks such complex mental states could never be simulated by computer, she feels the educational aspects of VR simulation may still be valuable, but not as they presently stand. "Without context, or if presented as a mish-mash of several people's experiences, I think the waters are being muddied too much. But presented in the context of someone's background, situation and wider mental state, there is potential for a richer understanding of their experience".
As a clinician himself, Cook is happy to acknowledge some of the shortcomings, admitting that some people "may have difficulty believing this sort of environment can be used for serious education". Although even with the potential drawbacks, feedback from his Second Life project has generally been very positive. The majority of visitors said that although they found the experience disturbing, they also found it educational and would recommend it to a friend.
Hoping to overcome some of the conceptual difficulties, an alternative approach has been tried by researchers from London's Institute of Psychiatry. They recently created a VR simulation of a library, where simulated people mill around or sit reading. Instead of trying to replicate radical changes in perception, their environment is designed to be as stable as possible. Crucially, they ask participants in the project what they thought of the other, virtual library users. They are interested in a certain subset of their participants who experience the people in the library as suspicious or malevolent, despite them being designed to act in an entirely neutral manner. By creating a controlled environment, and assessing how some people interpret a non-threatening situation as menacing, researchers aim to get a handle on the psychology of paranoia, one of the aspects that other 'virtual psychosis' projects have not been able to successfully tackle.
Ultimately however, it may be impossible to simulate the full experience of psychosis whichever technique is used. Yet prototypes such as the Cook's Second Life simulation may be having a positive effect none-the-less. Education is an ongoing process and can be accomplished with tools much simpler than high-end computer hardware. In this case, virtual reality is perhaps better considered as a complement, rather than a replacement, for traditional methods of education. "It may not be perfect", Cook says, "but if it raises awareness about mental illness and makes people a little more understanding, the technology has been well used".