How Users Shape Virtual Reality:
The case of gamified rehabilitation Supervisor: Stuart Blume Caleigh Farnsley Student #: 11002069 Medical Anthropology and Sociology 21-06-2016 University of Amsterdam Word Count: 19,563Table of Contents Abstract………2 1. It’s Not Reality, It’s Virtual Reality! ………3 A Brief History of VR: from science fiction to scientific practice……….5 Transforming Care Practices in Rehabilitation with VR………..9 2. VR in Context………13 Read it on Reddit………13 The Respondents………19 Online Communities as Spaces for Sharing and Creating Knowledge………20 More Than Just Improvement in Care………21 Emphasizing the User’s Roles………23 3. More Than Mere Potential: The Expectations of VR Rehabilitation………..26 (VR)evolutions in the Field of Physical Therapy………26 Pushing Boundaries, Promoting Care……….29 Itsy: a mini case study………...32 4. VR Once a Day Keeps the Doctor Away?: “Self-Medicating with VR……….40 The “Correct” Way to Use VR?...41 Exceeding Expectations by Escaping Reality………..…44 Taking a Step Back: Viewing Subreddits as Virtual Spaces for Experiential Knowledge………..47 5. Towards a Virtual Future……….52 Speculation or Expectation? ………52 Conclusion………..56 Appendix……….60 Reference List……….60 List of Abbreviations………63 List of Subreddits in Multi-Reddit………63
Abstract Virtual reality technologies allow us to create, view and explore alternate universes as far as our imagination can reach. This ability to simulate real-world environments is being explored by those in rehabilitation and therapy specializations. With this year’s release of consumer version virtual reality systems, anyone can experience it for themselves in the comfort of their own home. Some consumers have already taken to exploring the therapeutic effects of virtual reality for themselves. As virtual reality technology does not lie solely within the jurisdiction of medicine, how may such a wide range of users affect the future development of virtual reality rehabilitation? Thus in this thesis I set out to answer the question, how is VR developing as a technology for rehabilitation and how do the users, both medical professionals and consumers influence this development?
Chapter 1 It’s Not Reality, It’s Virtual Reality! Have you ever wondered what it would feel like to be inside and even explore another reality, a virtual reality? With new consumer version systems such as Oculus Rift, HTC Vive, PlaystationVR and Samsung’s Gear VR all going on sale this year, the general public will be able to experience virtual reality (VR) for themselves in their own home, many for the first time. As with countless others before me, my own interest piqued when I experienced it for the first time this year. Though unlike others my first experience was not at a large convention or tech developer lab. It was simply in the bedroom of my friend who had saved money together with two others to buy Oculus Rift’s DK2 (Second Developer Kit) back in 2014. Having been familiar with virtual reality already and aware of what it was supposed to be like I thought I was adequately prepared for the experience. Yet this only made it all the more impressive when I entered the first demonstration and found out how disturbingly deceiving a VR experience could be. I was sitting at a desk, not the real wooden desk that had just been in front of me, but a virtual one filled with virtual notebooks, a Rubik’s Cube, pencils, pens, and to the right an old TV showing a fuzzy picture of a man who looked to be from the 1980s telling me that I was in virtual reality and that everything in front of me and everything I was about to experience was entirely computer simulated. I suddenly remembered to turn around and what I saw caught me by surprise. It was a dark room with a wooden floor (eerily similar to the real bedroom I was currently sitting in) and I could see my shadow, or rather my avatar’s shadow, sitting in a chair just as I was. I turned around, only to be shocked again because the desk I had previously been sitting in front of had disappeared and been replaced by a beautiful virtual field of grass and mountains where the wind was blowing and the sun was shining. I looked down and there I was, a virtual man sitting in an old desk chair. It is hard to describe the feeling of being in this position and even more so to understand how I, a petite twenty-three year old female so easily assumed the role of computer
animated man in dress pants. But when you are sitting in a bedroom, yet sitting in a desk chair in the middle of a field surrounded by mountains, it starts to get easier to just take these things as they come. I continued to look around and take in my surroundings while the virtual world around me continued to change to ever more spectacular and peculiar things. Each time I turned my head around, I would turn back to find myself sitting in a new scene. Sometimes the walls of the room I was sitting in would begin to get closer, making me uncomfortably claustrophobic. At one point I was sitting on the wrong end of an unbalanced beam at the top of a large building so as soon as I moved to look down, I plummeted downwards making my stomach churn slightly (I later learned this is called a “pit-demo” and every VR experience contains one). Before I hit the pavement though the scene quickly changed and I was in space floating comfortably and quietly while looking down at the planet Earth until all of a sudden it stopped and the Oculus logo appeared in front of my face, letting me know the demonstration was over. Possibly the strangest part of the whole experience was the simple action of taking off the headset and adjusting my eyes back to the real and finite space that was my friend’s bedroom. I was left with a feeling which I can only imagine is like coming down from a psychedelic experience. Things seemed duller yet I felt clear and completely baffled by the virtual universe that had just been my reality for the last twenty minutes. My experience, along with nearly everyone else who has ever tried a VR demonstration themselves, reminded me how easy it is to trick our brains into accepting what we see in front of us as reality. It is not that things looked particularly realistic, it was clearly all computer-simulated, but it felt like I was there regardless. This is the experience Oculus and all the other VR companies hope to give to the world this year. Yet with costs reaching upwards of seven hundred and eight hundred euros (of course not including accessories and the high powered computer one needs to use these VR systems) it seems unlikely that VR will be reaching enough people to truly change the world any time soon and for now it is a luxury technology. Outside of entertainment and commercial use however, VR is
changing one world and that is the world of rehabilitation. Recently there has been a movement in the field of rehabilitation to ‘gamify’ exercises, thereby making recovery a more motivating and fun process for the patient to complete. Moreover, the ability to create controllable, safe and realistic environments for people to interact in is revolutionary for rehabilitation as well as psychological therapy. The inclusion of VR into rehabilitation and the social context surrounding this inclusion is the topic with which the rest of my thesis is concerned. However, before I elaborate more on the development of VR in and for rehabilitation, it is important to understand VR’s history and historic expectations as modern piece of technology. A Brief History of VR: from science fiction to scientific practice As we are only just beginning to realize and utilize virtual reality technology, and many people are learning of its existence for the first time this year, it may come as a surprise that VR has a history dating back to the early 20th century. However, what the history of VR looks like and its exact timeline varies between people based on what they think the most important aspect of VR is. For example, if the most important aspect of VR is that it represents a new kind of escapism and sensory deception, then its history goes as far back as the first time humans used paintings, books, photographs and movies as a way to escape from daily life and take time to reflect (Ebersol, 1997). If VR is to be thought of as mainly a new gaming technology then its history looks much different, starting somewhere in the late 20th century when electronic game consoles became popular in homes all over the western world. As a tool for communication VR can be thought of as the successor to the telegraph, telephone and more recent development of video chatting (Bletter, 1993). Throughout its development, enthusiastic futurists have declared VR “an imminent transition in the ways humans would experience media, communicate with one another and even perform mundane tasks” (Fox et al., 2009, p. 95). As is the case with many new and emerging technologies, VR’s development, history and expectations for its future are understood and speculated about in various ways depending on which aspect is focused on.
Here I will focus on the hardware development and historic expectations that went alongside that development of VR technology. With these aspects in mind, the history of VR technology has been a frustrating cycle of high expectations and disillusionment. VR is continually a grand idea that we do not yet have the technology to realize. Each time a technological aspect is developed, the expectations have already risen higher: such is the frustrating cycle. In order to give an overview of the historic development of VR technology I will briefly outline its history in three sections: before the 1960’s, 1960’s to 2000, and 2000 up until this year, often dubbed “the year of VR”. Pre 1960 In the early 20th century leading up to the 1960’s VR was more than just an idea. While science fiction in this time helped us to imagine various designs and applications for VR-like technologies such as the “feelies” in Aldous Huxley’s Brave New World (1932) or Stanley G. Weinbaums Pygmalion’s Spectacles (1935), real life immersive experiences were being created with the technology available. The most notable were created for cinematic entertainment and military needs. As the cinema industry was booming, people wanted to expand the boundaries of what could be experienced in movies to include all our senses and make them as immersive as possible. Once it became clear that peripheral vision was important for immersion people started to come up with designs for screens and projections that curved or wrapped around the viewer (Lowood, 2015). However, as will become a theme in VR history, these inventions were expensive and hard to employ on a mass scale. This is why the military is often the first to adopt and create new technologies as they have the money and resources to do so. During the First World War Albert Bacon Pratt invented the “Integrated Helmet Mounted Aiming and Weapon Delivery System” which can be viewed as the earliest design example from which the VR head mounted displays get their form. While it was not in itself a VR system it must not be ignored as it later gave way to hardware designs such as the goggles over your eyes that project information and the fact that it had to be designed like a helmet (Bayer, Rash & Brindle, 2009). Drawing from the cinematic VR inventions,
the U.S. Airforce during WWII began using these early virtual reality screens and projections as flight simulators to train pilots (Lowood, 2015). This proved to be an ingenious use for VR and began the development of VR as a training tool, for which it is still widely used today because it provides a low cost and safe method to train new pilots. 1960-2000 While the early 20th century brought the very first technical realizations of VR-like technology, it was in the 1960s and the following forty years that VR hardware development really accelerated. Continuing to push the boundaries of cinema, Morton Heilig invented the Sensorama Simulator, a machine that immersed the viewer in an experience through visuals, aromas, sounds and wind. Some of the simulations, such as one where the viewer is given the feeling of riding a motorcycle through the streets of Brooklyn while the wind blows through their hair, their seat rumbles and the smell of the city hits their nose, are conceptually very similar to the VR demonstrations of today. Though the whole-body sensory experience didn’t stick in the development of VR it did pave the way for the 3D shows people experience today at theme parks and further steered the public’s attention towards the wonder of experiencing virtual worlds. What really made the 1960’s a defining moment for VR technology, though, was the invention of the head mounted display, the basic design which has become the most defining characteristic of modern VR technology and what many of the commercial versions of immersive or 3D experiences, like the Sensorama Simulator lacked. Using previously conceived designs (similar in appearance to a ViewMaster or the military helmet mentioned above) Ivan Sutherland made VR history in 1968 with the invention of the first head mounted three-dimensional display with feedback and head tracking motion, which was called “the ultimate display” as well as “the sword of Damocles” (Lowood, 2015; Sutherland, 1968). This invention set in place the basic model for what VR would continue to look like. Today while there are many different brands of head mounted display, the most popular currently being Oculus Rift and HTC Vive, they are all technologically advanced variations of
this core model. With this model in place, VR began its cycle of ups and downs where it could only develop as fast as computer technology was developing. However, with the feeling of access to virtually realistic worlds being just around the corner people became frustrated with how bad VR systems really were. As electronic games and game consoles gained popularity and 3D graphics seemed to be getting better each decade, it seemed likely that an immersive VR system would be available by the late 1980s. Once again though, the technology was expensive and did not live up to people’s expectations, and lost the public’s attention. It was at this time the development VR outside of entertainment really began. 2000-2016 While it had already been established as a training tool in the military, those who studied and worked with VR hardware began to speculate about other applications it could be used for. In the early 2000s (and even still more recently) people were calling VR “A technology in search of an application” or even “an answer waiting for a question” (Rizzo & Schultheis, 2002, p.139 ; Foreman, 2009, p. 225). VR hopefuls and enthusiasts who still believed in the ultimate success of VR were proving that it could be used in a wide variety of instances. Similar to the flight simulator, people looked for other situations in which safe and controllable environments that could be created and made available at a low cost would be useful. In the last fifteen years VR technology has been able to develop beyond entertainment in the areas of education, business and medicine (Bletter, 1993). Each of these fields has helped shape the development of VR in different ways based on their needs. For education it is being explored as a training tool for pilots and surgeons and students are using Google Cardboard and Samsung’s Gear VR to take virtual field trips. In business VR is being used as another answer for an ever globalizing world. Business partners from across the globe can meet, shake hands and talk with each other without ever leaving their office. Medicine, specifically therapy and rehabilitation, may be the most involved in the development and utilization of VR technology. From using VR games to combat phobias such as arachnophobia (fear of spiders) and acrophobia (fear of heights) to using VR
systems to help a new amputee learn to balance and walk on their new leg VR is changing the world of rehabilitation and in turn, rehabilitation may change the way we think about VR. Transforming Care Practices in Rehabilitation with VR In the last decade virtual reality has carved itself a niche in the medical community as a game-changing tool within rehabilitation and therapy. However, as VR was not initially imagined and created with this application in mind, it is interesting to look at how VR as a medical and therapeutic technology has come to be. Currently the biggest markets for VR are the military, gaming, cinema, pornography and rehabilitation. While each of these uses VR for different ways and to produce different experiences they are intertwined in the way they have the power to collectively shape the way society thinks about VR as a piece of modern technology. Even more interesting are the ways different uses of VR have brought together disciplines that were previously quite separate such as gaming and medicine. New approaches to both gaming and rehabilitation are being realized due in large part to the inclusion of VR in both fields. Within rehabilitation VR has been and is currently being used for physical and occupational therapy as well as psychological therapy. In physical therapy it is used to regain balance, gait and motor skills among patients with issues ranging from mild to severe. Types of patients include stroke victims, amputees and patients with traumatic brain injury (Crosbie et al., 2006 ; Kober et al., 2013 ; Lewis et al., 2011 ; Sessoms et al., 2015 ; Sheenon et al., 2015). VR has also shown great promise for psychological therapy with applications that treat phobias, PTSD and anger management (Fox, 2009; Foreman 2009, Rizzo & Schultheis, 2002). Notably, these uses for psychological therapy are connected by the fact they can, in theory, all be treated using exposure therapy, for which VR turned out to be perfectly suited. With VR safe, controllable yet realistic environments can be created around and for patients needs in a way that has never before been possible. This development may aid in the evolution of not only how the public thinks about VR and its place amongst modern technology and society, but also the
hardware itself. When a technology begins to be used for a specific purpose, it often begins to change its shape to best suit that purpose (Bijker et al., 1989; Oudshoorn & Pinch, 2003) For example, in the case of VR for rehabilitation, the head mounted displays that are often thought of as the defining characteristic of VR are not useful and even a deterrent for someone learning to regain their balance after injury. Thus large projections connected to a treadmill or other robotic devices (reminiscent of very early VR designs for cinema) are being developed to better suit patient groups’ needs. However, as with many new technologies medical and non-medical, it is important to make clear who exactly the different user groups are, how do they use VR, and how does their use influence future development? In some cases, the users VR was intended for do not always accept it in the way it was expected. For example, VR in rehabilitation has been shown to be more favorable and successful with younger patients as opposed to older for various reasons, yet was also expected to be a new tool for the rehabilitation of stroke patients. As a greater percentage of stroke patients are older it would seem in this case, while VR could be a great therapy tool in theory, in practice it does not always work well with the actual patients it is meant to help. This could perhaps be mitigated if more research was done into how the elderly experience VR in comparison to younger patients. Perhaps different experiences resonate differently for different age groups and therefore VR applications, which are adaptable to these group’s preferences, could be created. Thus it is important to ask the question, in the case of VR development, who is involved in the development process and how do they contribute? VR as a rehabilitative tool is a particularly interesting case as the technology itself was not created for rehabilitation but rather, was adapted to fit it by the medical community. However, developing VR systems and applications takes knowledge that most medical professionals don’t have such as programming and engineering. A field full of people with expertise in designing, programming and engineering interactive experiences for different groups and genres of people is gaming. Thus, the two fields have collaborated and overlapped greatly in the last few years in the development of VR. Many of the applications come in the form of a game that patients play in
combination with traditional forms of rehabilitation and therapy. These games are particularly helpful with routine exercises in physical therapy that can become boring, demotivating and stressful for the patient going through it (Lewis et al., 2011; Rizzo & Schultheis, 2002). Repetitive exercises can be made fun by turning them into a virtual game in which patients have to earn points or explore foreign environments because they take the focus away from the repetitive motion the patient must complete. Creating these kinds of rehabilitative games means collaboration amongst not only game programmers and therapists but artistic designers as well. These multidisciplinary teams aim to create games that are visually interesting, therapeutically helpful and relevant to the distinctive groups of patients they are created for. This kind of collaboration not only creates new approaches towards rehabilitation exercises but also pushes the boundaries of what games can look like and be used for. The world of gaming is an ever-growing field proving that it is much more than playful games for entertainment but is in fact a medium to be taken seriously. I am then interested in what this collaboration looks like and how this collaboration changes the way we think about both the fields involved and new VR technology. In the rest of this thesis I will take steps that help me to answer my main research question, how is VR developing as a technology for rehabilitation and how do the users, both medical professionals and consumers influence this development? By exploring this question I will shed light on the difference between the expectations medical professionals and game developers have for VR rehabilitation and the experience of those who have used it for therapy on themselves. Moreover, I will look at the ways in which VR could be used as a technology that aids in the further professionalization of certain medical specializations and how online communities have an impact on this particular development. In the first chapter I have given a brief history of VR technology and explained how it turned from an idea into a piece of modern day technology that can
be utilized across different settings and fields. Furthermore I have introduced the promising field of VR rehabilitation and therapy as the focus of this thesis. In the second chapter I will elaborate on my methodology by describing how I conducted my research in an online space. In this chapter I will also take a moment to think about past technological innovation in healthcare, how users matter, and the ways experiential knowledge can be shared through online communities that may help to better understand the present situation of VR and its development in a healthcare context. In the third and fourth chapters I will present the data collected mainly through online interviews that help to show how medical professionals, game developers and users of consumer VR experience it for themselves. I will also discuss the ways in which VR may be a technology that helps specializations like physical therapy to further professionalize their field and distinguish themselves amongst the rest of the medical community. Through a mini case study of a therapeutic game I will discuss the ways in which independent games have an impact on the development in VR in quite unexpected ways. Furthermore I explore the role of online communities as contributors and creators of the knowledge that helps these independent games become relevant and successful. In the final chapter I will look to the future by talking about the impact of speculation on technological development as well as introduce some speculations about the future of VR made by my respondents and myself. Finally I will present some concluding remarks with regards to my research question and the topic of VR rehabilitation.
Chapter 2 VR in Context Read it on Reddit The research question that guides this thesis is, how is VR developing as a technology for rehabilitation and how do the users, both medical professionals and consumers influence this development? I aimed to look deeper into the world of VR and wanted to learn about how VR technology is being used and is expected to be used in the future, for rehabilitation of physical and psychological disabilities ranging from minor injuries to limb amputation to phobias. I intended to explore this question by conducting interviews with professionals and users as well as observe and participate in conversations people are having about this topic online. I started with making the decision to carry out the bulk of my research on Reddit.com. All of my interviews were conducted through Reddit.com, email correspondence, and one interview was conducted by video chatting through Skype. Thus, all of my fieldwork was conducted in a virtual space, which seemed only fitting for the topic. In the first half of this chapter I will elaborate on how I conducted research online using methods from cyber ethnography informed by my own prior experience of navigating the online world. As I said, the fieldwork site where I conducted the bulk of my research was Reddit.com. Reddit can best be described by its tagline, “The front page of the internet”. In one sense there is no such thing as a Reddit community as it is simply a vast collection of smaller communities, called subreddits. In another sense there is a greater Reddit community as each subreddit, while differing in size and content, run on the same basic set of rules. The defining quality of Reddit is that its content is entirely generated and regulated by users. This is done through a voting system, where users who have Reddit accounts can either upvote or downvote the content they see. Posts with many upvotes will be more visible than those with many downvotes. Interestingly, this voting system goes beyond content and is also present in the comment section. So, when someone creates a post and submits it to a subreddit, the post itself is upvoted and downvoted making it either rise or fall
amongst all the other posts. Then as people start to comment on the post their comments are either upvoted or downvoted. Thus, users regulate the visibility of all content seen on Reddit. Unlike most online chat rooms where the most recent post or comment is the most visible, on Reddit it is the post with the most upvotes that comes first. In order to get the best sense of Reddit it is probably best to simply go online and view it for yourself as Reddit can be viewed with or without a user account on any computer or smartphone. Without a user account, anyone can scroll through posts and read comments, but cannot contribute to the conversation. This way of browsing Reddit is what is known as lurking. To be sure, Reddit is no ordinary online forum. According to Reddit.com, in the month of April 2016 over 227 million people visited the website. On May 2nd 2016, over 3 million users were logged in and there are currently over ten thousand active subreddits. Thus, understanding how I was able to use Reddit to gather data about the more specific topic of VR and rehabilitation requires some explanation. In order to navigate the large online world that is Reddit, I first needed to establish a space within the vast community. Most importantly, I needed a way to manage and filter the information that was displayed on my front page and make sure I was only seeing posts and conversations that were relevant to my research. To do this I created a multi-reddit. This means I put all of the relevant subreddits together in one place where I can see all of the posts made within those subreddits. My multi-reddit was comprised of fourteen subreddits covering the topics of, virtual reality, rehabilitation and disability1. Every day I browsed my multi-reddit looking through posts and the conversations people were having about virtual reality, going through rehabilitation and living with disability. To give an idea of what a subreddit looks like, most posts are links to a relevant article, but before you click on the link you can see the conversation(s) reddit users are having about that article. Below is a screenshot of what the “front page” of my research multi-reddit looks like on a typical day. 1 For a full list of subreddits see appendix
Sometimes I join in these conversations by asking questions and contributing with what I know about VR. If someone commented something particularly relevant I would send them a personal message and we would continue our conversation this way. Besides “lurking” on my multi-reddit and participating in conversations I also made a few posts myself with the intention of finding people to interview. Here is an example of a post I made on the subreddit called oculus : Here is an example of what the reactions to my post look like (comments with an orange arrow next to it are my own) :
Once I introduced myself through personal message to a Reddit user, sometimes we would exchange emails and continue to communicate this way. Other times we would just continue to message back and forth within Reddit. While I did not conduct a strict cyber-ethnography I did use cyber-ethnographic methods and the methods I used to collect data require similar reflections. To begin with, I want to reflect on the anonymity of Reddit. Sometimes, gathering data online means doing so anonymously, and this can raise issues about consent. However, while Reddit is anonymous in principle it is in fact not entirely so. For example, with a user account you choose a username. This username is connected to everything you post, upvote, downvote and comment on. By clicking on a username, other Reddit users can see the history of a particular user such as what they have commented or posted. Thus, many Reddit users create what are known as “throw-away accounts” that are created with the intention of getting rid of them as soon as you have posted something you would not want traced back to you. So on Reddit, your username may not be your real name but within the Reddit community it is treated as such. That is why, within the community, it is considered proper etiquette or “rediquette” (a real term used on Reddit) not to share yours or
others’ usernames offline in order to adhere to the basic idea that Reddit is an anonymous place of sharing. This all raises an interesting conundrum for me and for my research when talking to people through Reddit. In most cases, I look at a user’s history and I see that in the last few months to a year they have frequently posted or participated in conversations within VR subreddits, which tells me (though not with full certainty) that they probably are who they say they are at least in terms of their involvement with VR. However, in one case, a user personal-messaged me but I could see that their account had been created only twenty-four hours earlier and they had never made a single post or comment other than the personal message to me, leaving me to wonder, did they create this account only to message me? Why would they do that and how can I trust what they say is valid? These are the kinds of questions I constantly had to ask myself when analyzing the answers from my anonymous interviews. Luckily, nearly all (except one) of the people I interviewed through Reddit explicitly chose not to be anonymous and in a few cases we even exchanged names and email addresses. This is lucky because it meant I did not have to worry as much about how anonymity could affect the answers I received. Beyond the anonymity of the people I interviewed, there is also my own role to think about. Having already had a Reddit account for about two years I decided to use that same account to conduct my research rather than create a new one specifically for conducting this research. It was not my intention to be anonymous myself; on the contrary, I wanted people to know who I was and to feel comfortable talking to me. This understanding of anonymity in relation to identity construction in virtual spaces is an issue that lies at the heart of cyber-ethnography. In the early days of cyber-ethnography beginning in the 1990s, people looked at online identities as decidedly separate from offline identities. In fact, much research focused mainly on the ways people used virtual spaces to create new personas, which they could live through in the online world (Robinson & Schulz, 2009). Early cyber-ethnographers created a picture of individuals who used the online world to escape offline realities and experience things they otherwise would not be able to in their physical body. This includes transcending race, gender and sexual orientation
(Robinson & Schulz, 2009). Interestingly, these kinds of observations are nearly identical to those being made about VR today. Whether it is academic or science fiction, writers have begun to envision a dystopic future where people live out their lives through virtual reality and their real life becomes too mundane to be a part of. Moreover, just as there was with the introduction of the internet, discussions are emerging around VR about the ways in which new technologies give people the possibility to create new identities. Though, again, there is a stark line being drawn between the virtual and the physical self. However, in more recent years this assumption has greatly changed in cyber-ethnographic practice and perhaps in the future it will change with regards to VR discussions as well. Now cyber-ethnographers have moved away from the idea of separated online and offline identities and instead towards the idea of identities that are co-constructed or integrated (Hallet & Barber, 2013; Robinson & Schulz, 2009). Today it is better understood that people construct their identities both on and offline in ways that overlap with each other (Hallett & Barber, 2013, p.323). They bring their offline selves to the online world. This is the view that I took while conducting my fieldwork on Reddit.com. While I understand that Reddit is also a place where people create multiple accounts and a fair amount of pretending goes on, this is more frequently done on subreddits outside of the multi-reddit that constituted my specific fieldwork site. I was also able to overcome this problem through personal messaging where my respondent and I would tell a bit about ourselves and in some cases exchange email addresses as a way to confirm to each other we are who we say we are. This relates back to my decision not to create a separate Reddit account for the purpose of conducting research. In many ways, my own Reddit user history is an accurate online representation of my “offline” life. Anyone who reads it can see that I like science fiction and Harry Potter, I have worked at a homeless shelter in Indianapolis, I am a student in Amsterdam and as of recently have started to do research in the field of VR. If I had to describe myself to someone offline I would probably mention some if not all of these things. Thus, my Reddit account is not a specifically online identity that I consider in any way to be separate from how I construct my identity offline because both are an accurate reflection of who I am.
This understanding of identity construction in online worlds is extremely important to think about when conducting ethnographic research online because it also helps make clear that online data collected is no less valid and online conversations are no less meaningful than those collected in a more traditional offline fieldwork site. In fact, realizing that online and offline identities are not so separate as they were thought to be at first has led to the further legitimization of cyber-ethnography as a practice. (Hallett & Barber, 2013 ; Robinson & Schulz, 2009). One final point of reflection is about the nature of the data collected from online spaces. It has been said that cyber-ethnographic practice, unlike traditional ethnography, eliminates a level of distortion in the collection process because the data is already collected as a text. In the online world, the researcher does not need to interpret as heavily what has been said because the respondent has already put their view into words through text, which means they are able to convey their own meanings more directly (Robinson & Schulz, 2009). However, for myself I still felt a lot of interpreting needed to be done on my part. Whether it is because of a language barrier or just general grammatical and spelling mistakes, I often had to look at the, sometimes quite vague, pieces of text that were sent to me and still interpret meaning out of them. Moreover, as the communication was not face-to-face clarification was not always easy to get. As a fieldwork site, Reddit provided an interesting and unique space to conduct my research and helped me to connect with people who would have otherwise been impossible to reach. The Respondents In order to find out how claims and expectations made by professionals compared to those of the users of VR for rehabilitation I set out to interview both professionals and patients, or ‘users’, currently involved in the field of VR and VR rehabilitation. The professionals I interviewed were physical and occupational therapists, a kinesiologist, a clinical psychologist/game developer, a medical software developer, and a VR therapy-game designer, all of whom had worked with VR rehabilitation and/or designed games for VR rehabilitation. Finding users, however, proved to be more difficult than I had first thought. While I first sought
patients who had used VR in a clinical setting, the responses I got on Reddit caused me to shift my focus to a different kind of user entirely. Many of the responses to my post on Reddit were from people who were using VR at home for medical purposes, but not in conjunction with any kind of medical professional. Thus the users I interviewed consisted mainly of people who are using VR for therapeutic purposes entirely at home. In the end I spoke with people who were using VR in a self-medicating kind of way for fibromyalgia, gender dysphoria and phobias such as arachnophobia (fear of spiders). By talking with these people and continuing to use Reddit to learn about the ways others were using VR therapy at home I was able to gain interesting insights into the ways users experience VR therapy and rehabilitation for themselves. Online Communities as Spaces for Sharing and Creating Knowledge In this thesis I focus on not only the professional users of VR but on the consumer users as well and because of this Reddit has a second role to play. Not only is Reddit the space where I collected my data (as described in the methodology section above) but it is also an object for observation itself. This is not wholly unique, as cyber-ethnographers in the past have noted the ways in which, “virtual text is both the data and medium through which participant observation is conducted” (Robinson & Schulz, 2009, p. 691). It is for this reason I want to first look more generally at the ways online communities and internet forums are used as places where individuals can share experiences and stories that can eventually lead to a production of collective learning and knowledge that can be reflected on and used by everyone. It has been shown that online forums can be a place for people to come together and form a community that revolves around the discussion of a particular health topic (Akrich, 2010 ; Lupton, 2014). What is interesting about these communities is that they are comprised of informal and often anonymous groups of non-professionals who seek to engage in conversation and learn through sharing experiences and providing support to one another (Akrich, 2010). These online forums represent an interesting kind of knowledge production that is based on personal experience but at the same time often fueled by ideas and terminology
acquired from the field of medicine. Within these online forums people not only share their experiences but also search for examples of other people’s experiences in order to better interpret their own situation. This process of sharing and reflecting is conducive to creating a concrete body of knowledge, though how exactly that body of knowledge is to be understood is unclear. In some cases, online forums are used in order to collect data about patients and patient care as a whole (Lupton, 2014). Through data mining, healthcare companies and other interested businesses take (or even buy) the data collected on online forums and use it to create more patient-centered policies (Lupton, 2014). In other cases, communication technologies can be used that allow patients with specific chronic illnesses to communicate with each other in real time and share coping techniques they have learned through their experience of living with a particular illness (Pols, 2014). More generally, however, it is important to understand that online forums revolving around particular health topics have the power to form communities that share experiences and practices which are eventually turned into a collective body of experiential knowledge that can be used by others and shared with other sources (Akrich, 2010). In other words, online forums and communication technologies (social media, texting, email and more) can be used to mobilize experiential knowledge. It is for this reason that in this thesis I look at the relevant subreddits on Reddit as online communities of people who share techniques they have developed to create and use VR therapy at home for self-care. In the fourth chapter I will elaborate more on the specific ways in which I observed and participated in conversations about using VR for self-care of various conditions. More Than Just Improvement in Care Given that the field of VR rehabilitation is, in practice, fairly new I was genuinely unsure and excited about what kinds of things I might discover throughout my research. As I set out to learn how the expectations of professionals and experiences of the users related to the different contexts in which VR was being developed I had some ideas and assumptions about the ways these two paths might oppose or support each other. On the one hand, consumer VR could be used as a
self-care technology with applications that seek to eliminate the clinician from the process. On the other hand VR could be a technology that, if used to conduct new research, could aid in the further professionalization of a particular specialization. In order to better understand this conundrum of VR as a tool for professionalization, though, it is helpful to first look through a perspective of innovation in health care and theories of professionalization. To better understand the medical professionals who expect and hope for VR to develop in a clinical setting, it is important to understand the role medical technologies and their use play in the overall culture of medicine and medical specializations. Technologies often reflect the interests and values of the current cultural climate, and this is also the case with medical technologies (Reiser, 2009, p. 186). There are various reasons why a medical practice chooses to adopt a new technology and sometimes these are motivated by things other than improvement in patient care, although this is of course a primary concern. One historical example of this is the introduction of the computed tomography (CT) scanner to the specialization of radiology. In this case, radiologists in hospitals wanted to acquire the CT scanner in order to generate research, improve their image, attract leading clinicians and generally give them an advantage over other hospitals and the rest of the medical community. (Blume, 2013, p.727). Thus, there was incredibly high demand for a technology that had no concrete evidence supporting why and how it actually improved patient care (Blume, 2013, p.727). More generally speaking, medical technologies provide specializations with the opportunity to make their results more visible and demonstrable to other specializations (Blume, 1992, p. 6). Sometimes when a profession is under pressure to legitimize itself it turns to methods that will help display scientific objectivity and quality (Berg et al., 2000; Porter, 1995). Using graphs, charts and numbers to communicate the results of your work is seen as being more objective and therefore more in line with the rest of the scientific community (Porter, 1995). There can be seen, then, a diminished interest of the patient’s experience and illness narratives in favor of more bio-medical understandings of illness and treatment (Bury, 2001). This emphasis on bio-medical and often quantitative explanations of research
results can have considerable impact on some of the more patient-centered specialization’s ability to distinguish themselves within the medical community. That being said, the complete control of medical knowledge with regards to information about illness and treatment has changed with the introduction of technologies like the internet that allow patients to exchange knowledge and experiences in an informal and non-clinical setting. However, in the context of healthcare, professional status is still being transformed by increased standardization, organization and rationalization of the knowledge produced and published (Petrakaki et al., 2012, p. 430). Taking the opportunity to adopt a technology that will help a specialization to produce this kind of objective knowledge that is desired can help them to further professionalize their field. Understanding the different motivations, beyond improvement in care, that influence a specializations decision to adopt a new technology is important for this thesis because it may help me to gain a better understanding as to why VR is being pursued by some medical specializations. Emphasizing the User’s Roles Given that my focus in this thesis looks heavily towards the users of VR both in a clinical setting and outside of it, I want to also look generally towards the different notions and conceptions about how users use technology and how their use can influence its development. This is a key component of my thesis as it helps me to contextualize my main question about the ways in which specific kinds of users (in this case professionals and non-professionals) in separate settings impact the overall development of a particular technology. The process of figuring out who exactly is going to use a technology and how they will use it is something all creators and designers of a technology must deal with (Oudshoorn & Pinch, 2003). Sometimes, the user group a technology was initially designed for changes over time and this in turn gets reflected in the future development of the technology. Information technologies in particular are noted as highly adept at anticipating user’s needs as it is well understood by now that the technology would be for nothing if people do not know or cannot easily learn how to use them (Oudshoorn &
Pinch, 2003). In this thesis I try to look at users and technology as not separate from each other but as equally influential to one another. This is because, as will be shown, users must adapt an already existing technology to fit their needs but in turn this adaption can influence the way the technology develops in the future. So the development process is never ending even after the technology is on the market because of this fluid interaction between users and technology. Thus, I move away from the SCOT (social construction of technology) approach as suggested by Bijker and Pinch (1989) because it treats user groups as decidedly too separate from one another. In this thesis I want to look not only at the ways in which user groups interact with technology but also if and how user groups interact with each other as well as how boundaries are crossed and previously quite separate groups with different fields of interest are brought together by new a technology. For this I must then consider the subsequent critiques of the SCOT theory by Kline and Pinch (1996) and later Kline and Kleinman (2002) that help to clarify the ways in which some social groups go unnoticed or whose influence is underrepresented due to existing social structures. This is particularly relevant for my thesis as I explore distinctly different and complex social groups including medical professionals, game developers, and general consumers each of which may have different social standing and therefore influence over the way VR is developed. While this thesis focuses heavily on users I also want to briefly mention the role of non-users, something Wyatt (2003) focuses on with regards to internet use. Throughout my research I found it fascinating to simply observe the crowd of VR enthusiasts who, already in this early stage, believe that VR is a technology of unfailing good and unending benefits. I frequently came across the notion that the only people who do not believe in VR are those who have not tried it. Therefore I think it is important to quickly reflect on the ways in which ‘those who have not tried it’ or non-users also influence the way VR is viewed by society. In the early days of the internet it was assumed that access to the technology was the only reason why people had not accepted it (Wyatt, 2003). As it is there are a large number of different reasons why individuals or particular groups of people do not or choose not to adopt a new technology. Given that VR is in an early stage of
development and the discussion of users is thus not in hindsight, perhaps it is important to keep the role of non-users in the back of our minds as more research continues to be done about the influence of users on the development of VR. In what follows I will use the notions of professionalization, user’s influence on technology, and the contribution of online communities to help me better understand how VR rehabilitation is developing both within and outside the clinical setting.
Chapter 3 More Than Mere Potential: The Expectations of VR Rehabilitation With this research I intended to better understand the up and coming world of VR rehabilitation and its development by analyzing some of the claims and expectations made about it by medical professionals and game developers. In this chapter I will describe and discuss what I have learned through interviews I conducted with both medical professionals and game developers. In the last section of this chapter I will conduct a mini case study of the game Itsy, which I use as an example of the way VR rehabilitation in a clinical and consumer setting overlap with each other. The claims and expectations given to me by the medical professionals I interviewed about VR rehabilitation, its current state and its future, are overwhelmingly positive. When asked about the future of VR rehabilitation professionals responded using words like, “amazing”, “a game-changer”, “enormously excited” and “great potential”. The enthusiasm from medical professionals and game developers alike comes not only from thinking about what VR can do for patients, but also what VR can do for the professionals themselves and the evolution of their specialism. For the medical professionals pursuing VR, such as physical therapists and clinical psychologists, VR is a technology that improves the kind of care they can administer but is also capable of collecting data that can help further their respective specialisms in the eyes of the scientific and medical communities. For game developers, VR presents a new audience to create games for and pushes the boundaries of the field itself beyond entertainment and into the medical world. (VR)evolutions in the Field of Physical Therapy The claims and expectations for VR are not only hopeful for the improvement VR will bring to care for patients but also for the improvement of the field of rehabilitation itself, particularly physical therapy. As mentioned in the previous chapter, sometimes improvement of care is not the only reason to adopt a new piece
of technology. The field of physical therapy is in a state of having to constantly prove itself to the medical community as a legitimate and science based medicine. They want to further professionalize their specialization. Thus VR may be a technology that can provide them with the opportunity to innovate and distinguish themselves amongst other specializations. The novelty and relevance of VR this year in particular may influence an organizations decision to adopt it. In the beginning of this thesis I briefly explained the ways in which VR has, in the past, been thought of as a technology in search of an application. As there are now years of research describing the efficacy and benefits of VR for rehabilitation, the field of physical therapy and its use of VR may take advantage of the hype and popularity around VR as more people are beginning to follow the development of VR through the media and consumer versions. The hype around VR may also help physical therapy in the ways of implementation. Theories about technological innovation and adoption suggest that increasing positive attitudes of employees towards a new technology also lead to an increase in their usage of the technology (Thakur et al. 2012). This may seem obvious but in the case of a technology like VR that is sometimes perceived and portrayed in the media as unnecessary, technological overkill or even a gimmick, it can make all the difference if professionals have a positive attitude about the technology during this introductory stage. As this year seems to be a time for VR where expectations and excitement are at an all time high, driven especially by the media’s attention to VR, it is not surprising that this is also the time we are beginning to see VR enter the world of rehabilitation in physical therapy classrooms and in practice because therapists see the benefit and the relevance and are initially willing to take the time to learn how to use the new system. In order for a technology to be accepted as an innovation it needs to not only be perceived as easy to use but it needs to also be perceived as useful. This is the basic tenet of the technology acceptance model (Thakur et al. 2012). More generally, a new technology should provide specializations with the opportunity to make their results more visible and demonstrable to other specializations (Blume, 1992, p. 6). Perhaps now that physical therapy feels under pressure to legitimize itself it is
turning to the collection of data provided by VR to help display scientific objectivity and quality (Berg et al., 2000; Porter, 1995). For the field of physical therapy, VR is perceived as a useful tool to collect data that improves research, diagnosis and therapy overall. It can be used to collect much more precise data about range of motion that will help doctors better diagnose, monitor improvement and further create a treatment plan for patients. Michael Aratow from VRecover expects that VR may even introduce physical therapists to new kinds of metrics and data for diagnosis and therapy that are currently unknown. A kinesiologist I spoke to named Maxwell was part of a team that researched the benefits of VR games in rehabilitation of stroke patients and autistic children even before head-mounted displays were available to them. He noted data as the greatest benefit of VR for rehabilitation. “Upside is the data! The tracking is amazing and was able to reveal subtle micro-stutters and [the patient’s] ability to track and hit a target [as well as] the micro adjustments they made at the end to be super accurate.” Data collection then is an area where the adoption of VR could benefit the field of physical therapy as a whole. Rehabilitation and physical therapy in particular have struggled in the medical community to prove themselves a legitimate science-based medicine, but the new data may help them further professionalize their specialism. “A lot of PT is really frustrating because it is like a new medical field and I feel like therapists are constantly trying to prove we are also scientifically medically research based…It’s frustrating though because it’s harder to do studies on this kind of stuff both virtual reality and kinect because it’s like a lot of training right, you have a whole process, it’s not just putting someone on a drug I mean Lilly2 can run studies so much faster than any rehab lab and there are so many factors to control.” (Katie, PT student) 2 The pharmaceutical company Eli Lilly.
The data collected by VR in rehabilitation studies and the ability to run studies faster may help physical therapy and other kinds of rehabilitation within the medical community to further legitimize and professionalize itself as a field of medicine. With the data tracking and collection capabilities of VR, medical professionals expect to be able to determine the efficacy of certain methods faster and therefore further the field at a quicker pace than it currently is. Already there is an increase in the number of publications aimed at discussing and determining the effects of VR therapy as therapists and patients alike learn to implement and use VR correctly. In my interview with kinesiologist Maxwell he mentioned that one of the downsides he saw in VR is that it can be complicated to learn initially. “The systems can be finicky, the interface can be finicky. It takes time to train users on how to successfully interact. Depending on length of treatment you could potentially spend more time training than treating.” This is not a particularly unique or even unexpected problem however as it always takes a certain amount of time for a new piece of technology to reach closure and become fully integrated into a social system (Bijker & Pinch, 1989). In the case of VR, it is an extremely interactive technology, which means a certain amount of learning needs to be done by both the patient and the doctor. Pushing Boundaries, Promoting Care It is important to recall the ways in which a new technology, through their design and use, can reconstruct pre-existing boundaries both within and around specialisms (Petrakaki, 2012). In the world of gaming, VR does just this. In the last few years there has been a dramatic shift in the way people think about games and the medium of gaming as a whole, exemplified by the increasing number of peer-reviewed publications on the topic. The implementation of VR rehabilitation has taken this topic of serious and applied gaming to an entirely new level. Rehabilitation of all kinds has put an increased focus on ‘gamifiying’ rehabilitation
practices and exercises aimed at motivating patients. In turn this has pushed the boundaries of gaming entirely beyond entertainment and towards care and medicine for the first time. Moreover, not only are therapists gamifying practices in their offices but we are beginning to see consumer games with explicitly therapeutic goals such as the game Itsy, a game that takes techniques from exposure therapy to treat arachnophobia, and DEEP a game controlled entirely by deep breathing exercises for people with anxiety. This integration of gaming and medicine means integration of the professionals themselves as well. To create VR rehabilitation games a team consists of professionals with both medical, programming and game design background. Today, many games are created using the game engine called Unreal Engine 4. In the future, medical professionals could potentially be taught to use this program as it does not require extensive knowledge in programming, but for now people trained in designing games are used. Game developers, like medical professionals, have high expectations for VR rehabilitation. In some ways their expectations differ as game developers naturally have different interests in VR that are not purely medical. In other ways their expectations are surprisingly similar. For example, one way in which game developers echo medical professionals claims and expectations for VR is in the area of data collection. A medical software developer I interviewed named Gary said one of the greatest benefits he saw in VR was: “New discoveries in the way that patients react to certain treatments/scenarios. A change to gather an enormous amount of new data leading to new medical breakthroughs.” The same medical software developer also mentioned he is interested in the idea of integrating VR into a greater electronic health records system. In many cases, VR rehabilitation is carried out in a hospital or other medical office and is being designed by a collaboration of medical specialists and software developers similar to the scenario explained to me by Gary:
“With regards to medical software in general, it is broken down into small pieces (demographics, problem lists, labs, doctor management, procedure lists, etc) and each of these "modules" has a specification written for it. So, work flow specialists write this specification (how it is meant to work). At this point, they will liaise with medical professionals (doctors/nurses/therapists) to get a true feel for real world workflow. This will then be integrated into the [specifications]. The same process is followed with regards to game/3D simulation design. Through brain storming, the work flow specialists and medical professionals determine what the user interface (or game appearance) will be like in order to most efficiently facilitate the given task. The developer then receives this spec and determines the best way to implement it, given the technology (software capabilities) they have at their disposal. Deciding what kind of games/software needs to be designed is all down to the market that we target. This decision is made by upper management and strategy officers.” In this case, then, medical professionals and developers work together within a clinical setting. To frame it another way, game developers are operating within the boundaries of the medical community. This is not always the case with VR however. Within the culture of gaming there has been a recent increase in independent game developers and smaller teams of only three or four people are beginning to develop increasingly popular games considered groundbreaking because they diverge from popular games and gaming culture. For example the puzzle solving game Ether One Redux allows players to gain a new sense of empathy by stepping into the shoes of someone with dementia. This kind of storyline for a game was previously unheard of before the rise of independent game studios. Some of these new games are actually therapeutic games targeted at a very specific group of people such as those with anxiety or phobias. One example of this is the game Itsy.
Itsy: a mini case study Itsy is a virtual reality exposure therapy game with the goal of treating arachnophobia. The creators have taken methods from traditional one-session exposure therapy, whereby a patient is gradually exposed to their fear over the course of one three hour session, and gamified it using virtual reality (Miloff et al., 2016, p. 4). While inside the virtual environment users must interact with spiders that become increasingly more realistic as the game goes on, by completing tasks that encourage sympathy for the spider such as protecting it from the rain or keeping it fed (Miloff et al., 2016, p. 5). Through an interview with the designer of the game, William Hamilton, I learned that the hope for Itsy was that it would prove “direct to consumer VR treatment apps” is indeed a viable concept. “The whole point of the application is providing exposure therapy in a self help context and provide treatment without a therapist and even any contact with the clinical establishment.” Having spoken to both a developer, William, and one of the users, Allison, I would like to use the case of Itsy as an example of what the future of VR therapy might look like, and how users like Allison and others I spoke with on Reddit could change the way users think about using VR in a way medical professionals and game developers did not expect. Having already given a brief explanation of the game above, I would like present the description of the game as given to me by one of the developers himself. As he explained it Itsy is, “A series of games and tasks with increasingly scarier spiders as the game progresses. All of the spider interactions are "positive" IE you never get to "kill" spiders but rather protect them from rain using an umbrella controlled by your head movement, or feeding them, or playing "spider memory".
The whole point of the application is providing exposure therapy in a self help context and provide treatment without a therapist and even any contact with the clinical establishment.” The game can be bought online for three dollars. Of course this does not include the cost of the VR system you need to play the game, but as the game runs only with gearVR3 the cost of playing this game at home may still be a considerable cost savings as opposed to going to a psychologist for traditional exposure therapy treatment. A cost savings such as this could be great incentive for users to choose an at home treatment instead of, or at least before, going to see a doctor or psychologist. However, William’s expectations for the game were not so high as other developers I interviewed. He told me his initial expectations for the game were quite low, and he was doubtful as to whether they would be able to create something that had any real therapeutic effect. To some degree his expectations reflect the reality of the efficacy of Itsy, as it has yet to have been shown to eliminate arachnophobia as well as traditional exposure therapy is meant to. So far it has been described basically as the first step, but not the solution. One comment about the game on Reddit stated “I’ve gotten my fear from paralyzing, to “I respect you spider, I respect you from across the room”. Pretty alright with that level there.” While Itsy may not be a replacement for exposure therapy or traditional methods of treating phobias, especially phobias much more debilitating than arachnophobia, it is certainly a step in the right direction and proves that people can use VR to at least manage arachnophobia without the help of a therapist. Allison, the user I spoke to, seemed to have mixed feelings about Itsy that I believe reflect other responses I have read online, such as the one quoted above. 3 A smart phone connected to a head mounted display and currently the cheapest VR headset on the consumer market selling for around $99 excluding the smart phone.
Allison has been dealing with arachnophobia for years now and started to feel it was only getting worse as the years went on. Moreover, she had started to feel she had less control over her fear of spiders than she would like. While she told me she had been to therapy for situational anxiety, she said she had never done anything about her increasing fear of spiders. The game Itsy was recommended to her by her boyfriend and she decided to try it out at home. Interestingly, while there is, of course, no therapist present the game does employ what William referred to as a “virtual therapist AI” that guides the user through the game and even tells them to slow down or go back if it thinks they are reaching unsafe levels of anxiety and discomfort. Allison described it like this, “I put the headset on, my setting was a bedroom in a home. We used the samsung gearVR. Immediately I was told by the VR therapist that I was in a safe environment and there would never be a spider in this room I was seeing. My VR therapist explained to me many things about the process and what the possible outcomes could be. I have done 2 sessions of VR therapy so far. I was able to compete the Itsy program once through the two sessions. I would say each session was approximately 35-40 minutes. That is all I have completed so far although I do plan [to] continue with treatment.” The first thing that intrigued me about Allison’s response was the language she used to describe the event. Perhaps it should not be surprising, but it is interesting to see her say use phrases like “continue with treatment” and “my VR therapist”. The VR therapist is an AI built into the game like many games that employ an artificially intelligent narrator4. However, in this case the AI is not just a narrator it is a therapist and Allison is treating the relationship with her AI therapist similarly to how she would treat a relationship with a human therapist. Moreover she uses the phrase “continue with treatment”, which sounds more like she is taking a round of 4 The Stanley Parable is noteworthy here as the core feature of the game is how the player chooses to interact with the AI narrator.
prescribed pills and indicates to me that she does consider Itsy to be a form of legitimate treatment. However, she does realize it may not make her fear of spiders disappear entirely, “I am still certain[ly] afraid of spiders and I know that it is possible my fear may never completely disappear. My goal of using VR for arachnophobia was to help make my anxiety more manageable when I see a spider” That being said, when it comes to Allison’s experience I am interested in more than just the practical observation of whether or not the game achieved what the developers expected it to. I also wanted to know how she experienced it as it was happening; was it enjoyable, did it make her sick, and how did she feel about it beyond its efficacy? What was somewhat exceptional about Allison’s experience is the mixture of feeling it was effective even though it was actually an unpleasant experience. “My experience with VR was not exactly enjoyable. It caused a lot of anxiety and took a lot out of me emotionally and mentally. It was a hard process. But I think that is true of anything when you are facing your fears head on. I do consider it a positive experience though. I felt accomplished knowing I was actively trying to combat a fear of mine. I felt like at least I was taking the necessary steps to have control over my arachnophobia. And while the game (Itsy) caused anxiety it was still fun to play the ³mini games/challenges² or tasks to help overcome your fear. There were no drawbacks to using VR for me personally. I did not feel nauseous or dizzy nor did I have any headaches due to VR.” Allison’s description of her experience perhaps reflects that of others who go through psychological or physical rehabilitation. There are obstacles and the process is not an easy one but the outcome is worth it. Of course what is different here is that Allison is doing it entirely on her own and without the support of a
