Distraction and presence in painkilling SnowWorld

[Excerpts from an article in GQ; an audio interview with the author is available from NPR]

[Image: Ari Hollander/Hunter Hoffman]

Burning Man

On his first tour of duty in Afghanistan, Sam Brown was set on fire by an improvised explosive device. He survived, only to find himself, like thousands of other vets, doomed to a post-traumatic life of unbearable pain. Even hallucinogen-grade drugs offered little relief, and little hope.

Then his doctors told him about an experimental treatment, a painkilling video game supposedly more effective than morphine. If successful, it would deliver Brown from his living hell into a strange new world—a digital winter wonderland

By Jay Kirk
February 2012


Hunter Hoffman hadn’t set out to help burn patients. As a cognitive psychologist—who had gotten his start back in the ’80s conducting experiments at Princeton to test the mind’s ability to discern between real and false memories—he had begun experimenting with virtual reality as a treatment for arachnophobes. Using a VR game he’d designed called SpiderWorld (see box), he had helped a number of individuals so crippled by fear that they had to seal up their windows to sleep. Outfitted with virtual-reality goggles, the patient began at the far end of a virtual kitchen, opposite the counter, upon which was a small, barely visible spider. Once the fight-or-flight response had subsided, the patient could inch closer until he could stand being close enough to see the spider’s reflection in the toaster’s chrome finish. Hoffman had created a world that people could enter, reemerging with their nightmares erased. It was an artificial world with the power to transform meaning itself in the so-often-insufferable sphere known as the real.

One day in 1994, a colleague of Hoffman’s told him he’d been observing patients at a burn center using hypnosis to control pain. His colleague wasn’t exactly sure how the treatment worked, but he thought it had something to do with distraction.

“Distraction?” Hoffman said. “I’ll show you distraction,” and he showed his friend SpiderWorld.

Not long after, Hoffman went to meet the hypnotist himself, who agreed VR sounded like a pretty good idea. On the very first burn patient they tried, SpiderWorld worked. He simply forgot to think about his pain. Still, stoves and toasters didn’t seem right, considering—kind of cruel, really. So Hoffman hired a world builder to make something else, something colder, fireproof.

Later, after Hoffman became director of the Virtual Reality Analgesia Research Center at the University of Washington Human Interface Technology Laboratory, or HITLab, he had some remarkable success. Using $35,000 goggles—the sort of hardware ordinarily used for training fighter pilots—researchers obtained drops in pain ratings by 30 to 50 percent.

If distraction was the key, why not just use over-the-counter video games for a fraction of the cost? To answer that question, Hoffman had run a control experiment. In his first case study, he had a teenager with a severe flash burn play Nintendo Mario Kart while having five staples removed from a skin graft. The data showed that in terms of reducing pain, anxiety about pain, and time spent thinking about pain, playing Nintendo Mario Kart compared poorly to SpiderWorld. The reason VR was so much more effective than a regular video game came down to a quality called “presence”—that sense of being immersed inside an artificial world.

In 2006, Hoffman presented his findings at a DoD conference on combat-casualty care. The most prominent image Hoffman had played on the screen had been a giant digital snowman, somewhat menacing in mien. Yet it was hard for all the high brass in the room to ignore the two 3-D brain scans comparing activity in the region of the mind known as the pain matrix. In the scan of a patient who had received only conventional opioids during wound care, the matrix was lit up like a cortical pool of lava. The other brain—the brain on VR—was a cooling star. “According to our results,” Hoffman said, “VR not only reduces pain perception; it changes the way the brain processes pain signals.” A day or so after the conference, he got a call from Colonel John Holcomb, commander of the army’s Institute of Surgical Research, or ISR, at Brooke Army Medical Center in San Antonio.

ISR was a unit born during World War II, in part out of the need to find better ways to treat thermal injuries, in anticipation of the waves of atomic-burn casualties that many reasonable, if gloomy, individuals regarded as inevitable. Ironically, sixty years later, those new techniques were being used more than ever, in response not to the most sophisticated weapons on earth but to the most crudely effective. An approximate 70 percent of injuries and deaths of U.S. troops this decade have involved an IED.

“Hoffman, we need VR,” Colonel Holcomb said when he called. “Make it happen. Get it over here.”


It was once he was off the ICU, in the step-down unit, that Maani came in one day and asked if Sam would be interested in taking part in a research trial. He consented, along with eleven other soldiers in the burn unit. He probably would have consented to just about anything now if it promised relief. Soon thereafter, doctors wheeled an apparatus into his room, a robotic-arm-type thing with what looked like a welder’s mask affixed to one end. This was the delivery system for a state-of-the-art virtual-reality game, they explained. It was called SnowWorld.


When they first lowered the goggles over his eyes, Brown was not all that impressed. He found himself floating through a kind of glacial canyon, but the overall vibe was pretty kiddie. Snowflakes wheeled gently from a digital sky. Snowmen and penguins lined up on ledges along the fjord. The soundtrack was kind of lame, too. Kind of an upbeat chirpy world music, a catchy-against-your-will kind of thing that he’d never heard before. If you’ll be my bodyguard, I can be your loo-ong lost pal, the lyrics went.

But there was no question Sam felt very much inside this Disneyesque world on ice, and it was a hell of a lot better than being present while they yanked and pulled at his petrified shoulders. So he tried to get into the game. A few milligrams of Dilaudid didn’t hurt.

The action of the mouse allowed him to fire off snowballs as fast as he could click. He had, more or less, a snowball M16. When one of the snowmen lobbed a big misshapen snowball at him, magically unholstering it from its hip with its stick arm, he took it out with three controlled head shots. The first shot turned the snowman to ice, freezing it with its arm served back, mid-lob. A third sent an explosion of ice shrapnel raining down into the canyon. Eerily, its disembodied face, the charcoal eyes and carrot nose and button teeth, lingered in the air for a few seconds afterward.

I can call you Betty, and Betty when you call me…

He passed under a low overhang, a kind of narrow passage in the bluish opalescent icy wall, strafed a couple of igloos, and then turned his attention to a squad of penguins flapping their wings further up the escarpment.

After a few circuits, he realized that each time he went through the cavern by the waterfall and then came back out, all the snowmen and penguins he’d killed were resurrected. It was a game that could not be won. So to make it more interesting, he began to test how to ricochet snowballs off the canyon wall and make carom shots. He started thinking trajectory. He thought ballistics, correcting his maximum ordinates before laying down wave after wave of penguin annihilation.

When he stopped shooting, he could hear the trickle of the river moving underneath him, and he took a moment to notice that he was suspended in air, floating along, out of his body. Everything moved in slow motion, just a few frames slower than reality, which was relaxing. As he passed beside the waterfall, he felt a tug of pain from the outside world but then directed his attention to the flying fish leaping below. He fired off a few shots, and his snowballs splashed up with blue steam.

Don’t wanna end up a cartoon in a cartoon graveyard, bone digger, bone digger.

Sam found out quickly that the woolly mammoths wading below were indestructible. Shoot them and they only trumpeted angrily, so he didn’t bother wasting any more rounds. Sometimes the snowfall waned, the sky turned blue, and then the snow started again. Between Paul Simon, the indoor waterfall, and the sedated peripatetic tempo, the whole place kind of had the feel of a suburban mall. Except, of course, here you could machine-gun everything in sight guilt-free.

The truth was, he was rather enjoying it. It wasn’t like he could feel a cold breeze blowing through his hair or any bullshit like that, but being down in that digital wintry realm, it did have a certain effect, enough that he found himself drifting back to the last time he’d gone skiing with Daniel, his brother, at the same resort in Colorado where his family had always gone on Christmas break, this last trip being during his final year at West Point. He and Daniel had gone skiing backcountry, off the trails, well beyond where the tourists went, so they had it all to themselves. They had found a bowl that was pure and untouched, the powder so deep they’d just floated down the whole way, the best skiing of his life. He also remembered the crazy stunt his brother had pulled that Christmas, cracking everyone up, when he’d gone on a black-diamond run almost naked, busting down the mountain in nothing but a pair of boxer shorts and red-and-white-striped elf tights, the pom-pom on his red Santa hat flipping back and forth. It was only as he got closer, almost to the bottom, that you could see the rubber skull mask, and when he skidded to a stop, his laughter was muted by the mask, the steam of his breath huffing out the rubber eyeholes.

Before Sam knew it, the game was over. His therapists were taking off the goggles. “We’re already done?” He still had a whole village of igloos left to liquidate.

When they went through the list of questions, Sam was surprised to hear himself say that his observed pain had only been a 6. The therapists were pleased, and maybe a bit surprised as well, to tell him that they had gotten more range of motion than previously.

“Really?” But it was true, Sam had only been vaguely aware of the pain, mostly when it had caused him to muff a shot. The game play was like a white noise that canceled out the pain—as great a relief as he’d gotten so far during therapy, better even than morphine.

Later on, Hunter Hoffman came in to explain how it worked. Sam immediately liked Hoffman, who must have been about 50 but had the wispy blond hair and boyish energetic demeanor of a surfer on some kind of mission impossible. He liked hearing Hoffman break apart the mechanics of how his mind and his pain operated. How giving pain attention meant giving pain meaning, and how meaning amplified the experience of pain. How his conscious attention was like a spotlight. “Usually,” Hoffman said, “it is focused on the pain during your wound care, but we’re luring that spotlight into the virtual world.”

Sam thought about one of the questions they had asked when he’d finished: “While experiencing the virtual world, to what extent did you feel like you WENT INSIDE the computer-generated world?”

0 = I did not feel like I went inside at all
1–4 = mild sense of going inside
5–6 = moderate sense of going inside
7–9 = strong sense of going inside
10 = I went completely inside the virtual world

He had answered “moderate” for that one. But everything was relative. When it came to being inside virtual worlds, he was a veteran. He knew a thing or two about immersion. SnowWorld did not even compare to KetamineWorld. KetamineWorld was a solid 10 for presence. Still, he fixed Hoffman with his brown eyes and said, “I think you guys are onto something.”


While he was suffering through his post-op recovery, Maani contacted him to say that if he was still interested, he could come back in for another dose of SnowWorld. He needed to demonstrate it for a few visiting officials. Sam leapt at the chance. He didn’t care if he had an audience.

But once he donned the goggles, the experience fell short of what he remembered. It still did an okay job, but now, somehow, the distractions—the music, the demonically happy snowmen, the exploding penguins—felt more like sensory overload. That, but also, he wasn’t a patient in this hospital anymore, nor was he caught in that lonely gray limbo of an apartment. He had a real home now, where Amy and a little peace and quiet were waiting.


Last July, Maani and Hoffman published the results of the study in which Sam Brown had participated. Echoing the civilian studies, soldiers reported significant drops in pain while immersed in SnowWorld. Time spent thinking about pain, which is an inextricable contributor to actual pain, dropped from 76 percent without SnowWorld to 22 percent with SnowWorld. Amazingly, some of the biggest drops were for the most severe levels of pain, which went against every previous expectation. Since then, SnowWorld has received a good deal of enthusiasm from several well-lit corners of the Pentagon. At least one four-star general, after seeing the results from the ISR study, has gone so far as to say that he foresees a day coming soon when VR pain distraction might become standard care. There is nearly equal excitement about Hoffman’s other applications, including one called IraqWorld, a virtual-reality exposure therapy he built to treat soldiers with PTSD.

Hoffman knows that more studies need to be done before VR becomes a regular part of a medic’s field kit. To that end, he and his colleagues at HITLab are now using $7.5 million in NIH grants to further investigate how VR affects the mind and how better to apply it in clinical situations. One part of the study is looking at using small doses of ketamine to enhance the sense of presence. But he is confident that eventually, as the technology becomes more sophisticated, VR will be exponentially more effective. Soon, he predicts, VR worlds will be customized, personally tailored, and as in social networks or Second Life, they’ll allow patients to bring along other people—a vet’s mother, girlfriend, buddies. Hoffman imagines programs that will tap into a patient’s happy memories—of a ski vacation or a honeymoon or a morning rowing on a river, sunlight dripping from the oars.

Hoffman can also see battlefield applications. Customized VR worlds will be pre-programmed right into the soldier’s eye gear. He’s already experimenting with piezoelectric crystals to that end. It doesn’t seem like much of a stretch to imagine a near future in which combat patients could simultaneously distract themselves from their own pain while inflicting it on a virtual and remote enemy. A soldier could put his mind inside a drone instead of watching as a medic changed his bandages. In such a future of techno-utopian warfare, at least for those combatants equipped to fight outside the pain matrix, victory will indeed belong to those who have rid themselves of the inconvenience of being men and who, for all we know, may as well bleed snow.

[snip to end]

Jay Kirk is the author of Kingdom Under Glass, just out in paperback.


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