Limits, inhibitions disappear online

WASHINGTON — A stroke four years ago left Susan Brown, 57, in a wheelchair with little hope of walking again. Today, the Richmond, Va., woman is using her legs and reclaiming her life, thanks in part to encouragement she said she gets from an online "virtual world" where she can walk, run, even dance.

Roberto Salvatierra, long stuck in his home because of his terror of going outdoors, started venturing outside more after gaining confidence by first tentatively exploring the three-dimensional, interactive world on the Internet.

John Dawley III, who has a form of autism that makes it hard to read social cues, learned how to talk with people more easily by using his computer-generated alter ego to practice with other cyberpersonas.

Brown, Salvatierra and Dawley are a few examples of an increasing number of sick, disabled and troubled people who say virtual worlds are helping them live with their disabilities and sometimes begin to recover. Researchers say they are only starting to appreciate the impact of the phenomenon.

"We're at a major technical and social transition with this technology. It has very recently started to become a very big deal, and we haven't by any means digested what the implications are," said William Sims Bainbridge, a social scientist at the National Science Foundation.

Virtual worlds also are used for other health-related purposes. Medical schools use them to train doctors. Health departments use them to test first responders. Researchers use them to track how epidemics spread. These increasingly sophisticated online worlds enable people to create rich virtual lives through "avatars," identities they can tailor to their desires: Old people become young. Infirm people become vibrant. Paralyzed people become agile.

They schmooze, flirt and comfort one another using lifelike shrugs, slouches, nods and other gestures while they type instant messages or talk directly through headsets.

Because the full-color, multifaceted nature of the experience offers so much more "emotional bandwidth" than traditional Web sites, e-mail lists and discussion groups, users said the experience can feel astonishingly real.

Participants develop close relationships and share intimate details even while, paradoxically, remaining anonymous. Some said they open up in ways they never would in face-to-face encounters in real support groups, therapy sessions or with family and friends in their true lives.

"You're in this imaginary world. People don't know much about who you really are. In that anonymity, in that almost dreamlike state, people express things about themselves they may not otherwise," said John Suler, who studies the psychology of the Internet at Rider University in New Jersey, noting that the experience can be especially useful for people with disabilities and those in remote areas where support groups or therapists are far away.

While the emergence of these worlds has generated controversy over the gender-bending, sexually outrageous, profiteering and even violent virtual behavior of some participants, their usefulness for meeting health needs has just begun to draw attention.

Power of the Internet

"There is a fundamental irony here," said Thomas Murray, of the Hastings Center, a medical-ethics think tank in Garrison, N.Y. "Avatars tend to be young, beautiful, and never age or get sick. But at the same time they can serve as an important way to share information about health."

Murray and others worry participants may neglect potentially more helpful real-life relationships or have unrealistic expectations about what virtual worlds can do.

Users and health-care providers may be rushing ahead, they said, without validating the usefulness of these worlds or identifying the dangers.

"We've seen the power of the Internet and what it can do," said Albert "Skip" Rizzo, a University of Southern California psychologist who treats traumatized Iraq war veterans with virtual reality.

"But as we all know, there can also be negative consequences. We really need to step back and think, 'What are the practical and ethical things we can do in the area of health, and what can't we do?' "

Still, an increasing number of major health organizations are using virtual worlds for public-health education, patient support and fundraising.

The Centers for Disease Control and Prevention tested a small "office" in the popular virtual world Second Life "staffed" by Hygeia Philo, an avatar named after the Greek goddess of health, and is planning a bigger, permanent presence.

The American Cancer Society has an elaborate "island" offering virtual lectures by avatar doctors, support-group meetings and other activities, such as an annual fundraising marathon that last year raised more than $115,000 in real money.

The March of Dimes is building a virtual neonatal intensive-care unit to warn about the dangers of preterm births. The National Library of Medicine is helping fund HealthInfo Island, where users can get reliable medical information.

Real-life insights

Meanwhile, scientists are beginning to study virtual worlds for insights into real-life health problems. Two teams analyzed a virtual epidemic of "corrupted blood" that devastated the World of Warfare online game for clues to how people might react during a real pandemic.

Some medical schools and health departments also use virtual worlds. A University of California psychiatrist developed a virtual psych ward echoing with disembodied voices to help caregivers better understand schizophrenia. Stanford University doctors built virtual operating and emergency rooms to train doctors. Britain's National Health Service built a virtual hospital.

So much is happening in virtual worlds that researchers at Harvard Medical School are planning to explore the possibilities at a seminar this month, and the National Defense University in Washington is hosting a conference next month about ways federal agencies can use the phenomenon.

Individual practitioners, meanwhile, are discovering virtual worlds. After meeting other health-care professionals in Second Life, which with 9 million members is among the largest, Lawrence Whitehurst, a family doctor in Culpeper, Va., founded the Second Life Medical Association.

"I don't diagnose, and I don't treat. What I try to do is provide medical advice and support for people undergoing real-world medical problems," Whitehurst said.

Some therapists, however, use virtual worlds to treat patients, in their real and virtual lives.

"It doesn't work for everybody, but it works for a large majority of patients," said Brenda Wiederhold, of the Virtual Reality Medical Center in San Diego, who uses the virtual world DigitalSpace to help patients overcome fear of public speaking and severe shyness.

Limitations, concerns

While Wiederhold said she treats only patients she has counseled in her office first, others offer therapy to patients they have never met or know little about.

"My clients' problems range from domestic love tangles to complex and difficult real-life situations," Elena Mangan, who counsels patients anonymously in Second Life from Britain, wrote in an e-mail.

Such anonymous counseling disturbs many therapists. Internet therapy denies counselors vital clues from subtle body language, affect and tone of voice, they said. And anonymity can carry risks.

"How do you ensure the patient's safety?" said Richard Bedrosian, a clinical psychologist at the University of Massachusetts Medical School. "Suppose they say, 'I'm going to shoot my girlfriend or kill myself.' How do you protect that person? How do you intervene?"

The biggest users of virtual worlds for health purposes appear to be individual patients. Dozens of support groups have formed by and for those with cancer, paralysis, strokes, depression, cerebral palsy, cystic fibrosis, autism and other ailments.

Susan Brown, the stroke patient, said encouragement from other survivors in Dreams, one of several areas in Second Life for people with disabilities, and the experience of seeing herself walking again, aided her recovery.

"It helped me visualize," Brown said through her avatar, Marie Hightower, during an interview in a virtual field near a virtual home she built in Dreams, as virtual butterflies flitted past. "I stumbled here just like I stumbled in RL [real life]," she typed.

Salvatierra, the agoraphobic, Dawley, the patient with Asperger syndrome, and others tell similar stories.

"It's kind of like getting your life back again, but even better in some ways," said Kathie Olson, 53, who uses a wheelchair, lives alone and rarely leaves her home near Salt Lake City. In Second Life, she roams about as Kat Klata, a curvy young brunette who runs the Dragon Inn nightclub. "I've met so many people. I can walk. I can dance. I can even fly. Without this I'd just be staring at four walls. Mentally it's helped me so much."