Ugly Lies the Bone

Interview with Howard Rose


Howard Rose, CEO of DeepStream VR, is a leader in the field of virtual reality. Recently, Olivia O’Connor sat down with him to discuss VR, pain management, and Ugly Lies the Bone.

Audience members at Ugly Lies the Bone can experience virtual reality firsthand in the lobby of the Black Box Theatre; one of the programs mentioned below, COOL!, is available for audience use after every performance. Check it out before the limited engagement of Ugly Lies the Bone closes on December 6.

Mamie Gummer as Jess in UGLY LIES THE BONE.

Mamie Gummer as Jess in UGLY LIES THE BONE.

Tell me a little bit about yourself. What is your work background, and how did you come to virtual reality technology?

My name is Howard Rose. I’m the CEO of DeepStream VR. I’ve been working in virtual reality for over twenty years. I’ll also put a plug in here for my longtime partner; his name is Ari Hollander. Ari and I first met over twenty years ago, back at the University of Washington at a laboratory called the Human Interface Technology Lab, the HIT Lab. The HIT Lab was really focused on taking virtual reality out of the military context, where it had been developed, and into more civilian uses. The founder of the HIT lab is a guy named Tom Furness, who was actually the first person to be doing VR. The HIT Lab was a great place, with a lot of great people and access to technology, and that’s what got me into this.

My background is actually in education and educational technology. About twenty years ago, Ari and I left the lab and formed a company called Firsthand Technology. Over the years we’ve done a lot of work in different kinds of VR applications, including a lot of work on health. That work has included treatment for post-traumatic stress disorder and treatment for phobias. It has also included games; we use games and virtual reality as a way to inspire people to take better care of their health and change their health habits and lifestyle. One of the most exciting discoveries is that VR is a really great way to help reduce pain. We have been involved in VR pain research for over ten years. We started as a collaboration with Dr. Hunter Hoffman and Dr. David Patterson at the University of Washington. This research of VR for pain control has helped advance our understanding of how pain works – the psychology and the neuroscience of it – and it’s also helped us understand what aspects of VR make it really effective.

We see the virtual reality program developed at the University of Washington, called SnowWorld, dramatized in Ugly Lies the Bone. And pain is obviously a huge part of our main character’s journey in the play. Can you talk a little bit about how our understanding of pain – and, as a result, how we go about pain management – has shifted in the past decade or so?

Yeah, that’s a very interesting question. There’s a number of aspects when you try to unpack what pain means. There’s the physical pain that we feel, which is if you step on a tack, or you have an injury or a surgical procedure, there’s a certain amount of nerve – physical – pain. But there are also other aspects to it, like anxiety. Say you’re at the dentist; a lot of people feel anxiety just sitting in the chair. And then there’s this other aspect, which is loss of control or agency. So when you’re at the dentist, you have anxiety about the pain and then you also feel you have no control over your physical state or what’s going to happen to you. Those things – anxiety and a loss of agency – actually contribute to our feeling of pain. The more stressed out we are and the more out-of-control we feel, the more amplified the pain. So pain is not just a matter of signals going to your brain. Your brain also has an active role in how you experience pain.

Virtual reality is a physical and a mental experience. So, simply put, the mechanism for virtual reality pain relief is that our brain really only has a certain amount of cognitive power, and attention acts like a gate. The more we can direct your attention away from the pain, the less pain you experience. So let’s look at those three things –  anxiety, agency, and physical pain – in terms of VR. The mechanism to deal with anxiety is immersion. VR is a very immersive experience. By engaging you in this immersive experience, we take you out of that stressful situation and we take you someplace else. To help with the loss of control and agency, virtual reality lets you be interactive, so you’re not just passively watching a video, you’re actively engaged in an activity; it’s an active experience. And third is the physical pain, which is reduced in VR by engaging and directing your mental focus. When you’re in [the virtual reality program] COOL!, you’re moving through a landscape and there are things to do; there are otters, and there’s stuff to play with; there’s a lot to engage your mind and engage your focus. That’s all working to absorb as much of your mental energy in the virtual experience as possible, so you have less brain power to focus on pain.

Can you talk a little bit about the initial tests of SnowWorld – who were those study participants, and what did those initial studies find about VR therapy for, in this case, burn victims?

Burns are a very important place to do research, and very appropriate. One reason is that burn pain is probably the worst pain you can have, in terms of intensity. And the patients who have extensive third-degree burns, they end up taking high doses of drugs. Safe doses of narcotics are not enough to relieve all that pain. It’s a good population to try to help, to try to reduce the amount of drugs that people need and to offer them something else, a non-pharmacological alternative for pain relief.

When we are in Virtual Reality, we feel it as a place we are in, rather than something distant and external that we are merely looking at. For example, when you see an image on a computer monitor or a TV, your mind picks up that the image is inside a  frame. That frame is a cue to our brain that we’re actually looking at something that’s outside of ourselves. When that frame disappears, we start to experience it as a place that we are, and that feeling of being enveloped in a virtual world is called immersion. We feel immersed – and we feel a sense of presence. The word “presence” refers to the tangible mental and physical feeling that you are actually in the virtual place.

The degree of immersion and presence you feel corresponds to the quality of the VR display, and the field of view. When we compared a VR helmet with a thirty-five degree field of view, for example, to a sixty-degree field of view or higher, we found that the wider field of view was important to deliver a stronger sense of immersion. So, in our research we did experiments where we varied aspects of the VR display or the virtual world, and measured the effect on people’s pain. In this way, VR pain research has helped us better understand the mechanisms and the phenomenon of virtual reality. So pain has given us a way to understand VR, as well.

And in those initial studies, if I understand correctly, there was this interesting phenomenon where people who reported the highest levels of standing pain also reported the greatest decrease in pain. Is that because VR tends to be most useful in terms of acute pain, rather than chronic pain, or is the connection not clear?

It’s an interesting pattern we see that VR seems to give the most help to the ones who need it most. For example, we built a special version of SnowWorld for Dr. David Patterson to use for hypnosis. The results showed that VR gave the biggest boost to people who were having the most trouble with hypnosis. Isn’t that great! And it’s really promising for VR in general.

So about acute versus chronic pain, let’s talk about acute pain first. Pain is a very personal experience. You and I can undergo the same surgery, and I might feel a completely different level of pain than you do. So when we study pain we like to compare the reaction of one person to different pain reduction treatments.  So everybody is different, and we build our virtual worlds, like COOL!, to accommodate for different personal styles and needs. For example, we provide lots to play with, to be very active with… or you can just relax and enjoy a ride through the scenery and watch the falling cherry blossoms. Our goal is to help you through a painful procedure or a relatively short amount of time by helping you relax and draw you into VR experience, so you feel less anxious and more engaged, and you have less pain.

As for chronic pain, it’s something completely different than acute pain. Chronic pain is not just prolonged acute pain, it becomes its own disease. And it calls for different approaches than acute pain. We’ve been collaborating with Dr. Diane Gromala at Simon Fraser University, using VR to enhance mindful meditation and build resilience for people with chronic pain. In an acute pain situation, like a burn session, there’s a start and then an end, and it’s a finite time.  You want to help people through a procedure. But for chronic pain, we’re not going to try to distract people 24/7. So the idea is that we use VR as a way to enable people to get moving, to get up and active, to engage... so in the short term they get a benefit from pain relief akin to what happens with acute pain, but in the long run our goal is to help them be more resilient and pain-free long after they take the VR helmet off.

For example, one of the applications that we’ve worked on with Dr. Diane Gromala is a Virtual Meditative Walk. It’s a very calming scenario; they’re walking through a forest and going through an audio guided meditation. The person walks on a treadmill and sees a virtual environment projected on a big screen. A biosensor measures the person’s level of stress and anxiety, and that data feeds into the virtual world to do biofeedback. So when the biosensor says the stress level goes up, the virtual world begins to fog over, reminding the person to calm their mind and relax through the pain.  This is really the cutting edge of where VR is going: virtual worlds with biosensors that sense our emotions and attention, and respond in real time.

I wonder if you can tell me a little bit more about VR’s history in the military. You mentioned that VR was first developed for military purposes, and I imagine that’s for training purposes. And now we’re seeing it – in addition to that training purpose – as a treatment tool for both pain and for PTSD. Can you talk about the inception of VR in the military, and now all the uses that it’s being used for in the military today?

Well, here I’d like to mention Dr. Tom Furness. Tom was one of the first people anywhere to do VR, as an engineer in the air force back in the 1960’s. Tom’s team was trying to deal with the problem of how you give crucial just-in-time information to a fighter pilot who is moving at the speed of sound in a way that’s useful, not distracting. And so they started to play with projecting information and video onto the pilot’s visor – called a heads-up-display. Gradually they started to expand the projection wider and wider, increasing the field of view, when all of a sudden, at a certain point, the pilots’ performance jumped dramatically. And then they went, “oh, look at that!” They had discovered this idea of immersion.

Back when I started in VR, all of this technology was repurposed from all those military applications I mentioned. So in the first VR project I worked on in the early 1990s, we took state-of-the-art computers out to public schools across Washington State.  The VR helmet we used weighed seven-pounds! When we put that on the younger children’s heads, it was so heavy that they all looked down at their feet. Not a great experience.

So VR technology has its roots in the military and it’s taken us a long time to get out from under those limitations. What’s really exciting and different about the new revolution in VR technology is that it’s driven by the computer gaming industry. So the size and the function of the equipment is much better for regular folks, and the software can do a whole lot more interesting things than just military simulations.

And projecting into the future, then, do you think that VR will be something that will enter the daily lives of most people?

One amazing thing is that we humans are walking around with a whole lot of untapped capacity. And the old way of dealing with computers, with a keyboard, a mouse, and a screen, is pretty limited in terms of what humans are capable of. What Tom Furness found way back then was that when the pilots’ performance increased, it was because the computer started to match the power of their senses and their minds, so they were able to gather information and react more quickly. The idea that virtual reality increases performance is pretty key to a lot of the uses in the military – battlefield simulations and those kinds of things. NASA is doing some really interesting things with astronaut training. In medicine you have a lot of people training doctors with robotic surgery, or having doctors practice in virtual reality.

Those uses of VR to enhance training are great. But the limitation is that VR for doctor training really focuses on the treatment side of the equation, and not on the patient side. Think about when you get sick. First, if you’re like me and most people, you try to avoid going to the doctor as much as possible. But sometimes we have more than we can handle on our own, so we go to the doctor with the expectation that the doctor is the one who puts us back together and sends us on our way. Of course doctors are important, but wouldn’t it be great to have a way to extend our own abilities to be healthy on our own? To unleash more of our own capacity for health and wellness?

This is the way we look at VR. It’s a tool to enable people to perform at a higher level. And in the broader sense of medicine, we’re trying to transition people from being health consumers to health producers. So we’re not just consuming health services, but actually become the engine of our own wellness. Instead of taking a pill, we tap into our innate capacity to be engaged, to be active, and to get through a procedure without the need of the drugs. Doesn’t that make sense?

I definitely think that VR’s going to be a major part of our lives in terms of education and health. It’s already starting to appear in more workplaces and contexts. You have the entertainment side, and you have games, and all of that energy goes into developing new technologies. I think that entertainment and games are great, but the real potential for VR is to improve people’s lives, to make us better at what we do. VR pain relief is really one of the best examples that we’ve found of a really good, beneficial use of VR. We’re really using the advantages of the technology and we can hook them to your biosensors and neurosensors.

Our goal is to make gains that adapt to you and get to know you – and that will help along the way in whatever goals you’re trying to achieve. I think the proliferation of VR is really kind of inevitable at this point. Imagine; not just five years in the future… think about, fifty years down the line, what the capabilities of computers will be. What about a hundred years from now? Virtual reality is going to be just woven into the fabric of everything we do.

Wow. I wonder if we can touch on SnowWorld specifically for a moment. We see Jess using the SnowWorld program in Ugly Lies the Bone, and our audiences in the lobby are going to be experiencing COOL!. Can you talk a little bit about what changes have been made in the programs – what kind of things you learned from the first iterations of SnowWorld that have now changed in COOL!?

To explain how we design VR applications for pain, think about how people design equipment for a  playground. When they design playgrounds for children, a lot of thought goes into building the jungle gym and the swings and the seesaws, so that kids arrive, get excited and just start playing. No long explanations; kids don’t sit around and think, “well, I’d really like to improve my blood oxygen, so I guess I’ll get on that swing for a half hour.” They just go and they do it.

Over twenty years building virtual worlds, we’ve learned a lot about how to make that experience and excitement happen. First of all, we want to make the barrier to success as absolutely low as possible. There are lots of tricks and approaches that conventional games use that just don’t work well for people in pain. Score is one interesting example. We intentionally did not put a numeric score in SnowWorld or COOL! We know that some people are motivated and engaged by trying to increase their score in a game, but for many people having a numeric score sends a much more negative message. We hear people say self-defeating things like “I’m not good at games,” but once they realize there is no score and nobody is going to judge their performance, they are able to relax and enjoy the experience.

We are also very careful about what kinds of virtual places and what virtual objects we put into the world. When you’re designing a virtual world, the only limit is your imagination. It can be absolutely anything, so it’s rather tempting to push the edge, to get far out and fantastic, artistic or philosophical.

Unfortunately, we’ve found that most people don’t feel very comfortable when the context gets too far from what’s familiar. So we walk the line between spaces that are immediately comforting and those that don’t lose the fun and imagination of what a virtual world can be.

I hope people will stop by after Ugly Lies the Bone and check out our latest game, COOL!, in the Black Box Theatre lobby. COOL! is a natural landscape that takes you on a journey through different seasons. You’ll also find some very playful otters there, who invite you to play paintball with them. It’s all good fun, but we also hope that people will come away with a better understanding of what VR is and how it can do some very practical, wonderful things for real people.

You asked about the advancements between SnowWorld and COOL!; COOL! is, graphically, it’s much much richer. The capabilities of the modern computers are far better than what we had when we started building SnowWorld. So the graphics are much better. And we’re bringing in biosensors and biofeedback as a key component to modulate the experience. And I think that that’s going to really provide a lot of benefit in the long run.

And when you say “modulate the experience,” you mean that the program actually changes depending on the feedback it’s getting from the user?

Right. So if you think about someone who is undergoing a procedure…  you think about a visit to the dentist, for example. It’s not intense pain the whole time, right? There may be intense pain while the dentist is drilling, but it goes up and down. And you may be very stressed out in the beginning, when there’s no actual physical pain happening, which may call for a very different type of relief than during the cavity drilling. So we use biosensors to track that level of anxiety through your heart rate or your skin conductance, to monitor how you’re feeling. If you’re stressed out we tell the virtual world to react to you and to respond accordingly. And there’s a number of channels that we can use to do that, whether through the types of activities, or the level of intensity, or the audio…there are a lot of ways that we can refocus your attention in a very deliberate way, and we modulate that level of intensity according to what you need.

I think Ugly is going to be so interesting because it touches on some issues that are hard to fathom in our daily lives, but it does it in a really accessible way. Have you had a chance to read the play?

Yeah, yeah I have. I think it’s great. There are two aspects of this play that I think are important for people to understand. One is the idea that the United States is at war, and we’ve been at war for a very long time, in Afghanistan and Iraq. Most people have the luxury of ignoring that. But if you go to a military base, it’s very apparent that the United States is at war. Soldiers are going off and coming back wounded all the time.  I think that that’s something that people need to be more in touch with.

And the other is this concept of pain. I think that we have a natural reaction to try to move away from pain. We don’t like it as a topic; we don’t like to discuss it. It’s unpleasant, and we just don’t want to go there too much. I love that the play brings those two aspects into focus and makes them real for people in the course of a dramatic presentation. I hope that the play will help people engage. And then once they engage, I think people can get a lot of personal value out of the story. Because pain is a part of all of our lives, and we’re all going to be in a position where we are in the hospital, or we’re injured, and we have pain. The more we understand pain and the more we understand our individual capacity to deal with it, the less we feel like we’re a victim, the more agency we have, the less anxiety we have, and the better the outcomes will be for all of us.


Ugly Lies the Bone plays through December 6 at our Black Box Theatre. For more information and tickets, please visit our website.

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2015-2016 Season, Ugly Lies the Bone

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Ugly Lies The Bone: To Watch


Immerse yourself in the world of Ugly Lies the Bone with our list of five things to watch.

HBO: Documentaries: The Alzheimer's Project: Watch the Films: Caregivers


This multi-part, multi-platform HBO documentary covers Alzheimer’s Disease, which currently afflicts over five million Americans, from the perspectives of patient, caregiver, researcher, and physician. Across a documentary series, online videos, a book, and public education and outreach, the documentary and its surrounding programming seeks to explore research on and treatment of Alzheimer’s as well as the everyday experience of the people and families affected by the disease.


“End of an Era for Shuttle, and NASA”
CBS News

“High Joblessness in the Home of U.S. Space Flight”

60 Minutes

Ugly Lies the Bone takes place in Titusville, Florida, at the very end of NASA’s shuttle program, and, as playwright Lindsey Ferrentino writes, “the end of an era.” These two videos capture this recent history and its aftermath. The first, a brief video by CBS News, traces the history of the shuttle program and its place in American history and mythology – and explores the potential future of manned space flight in the United States. The second, a “60 Minutes” profile filmed nearly a year after the shuttle program’s end, discusses job loss in Florida following the shutdown. For more in-depth coverage of what the final shuttle launch meant for the US space program and the Florida economy, check out these Men’s Journal and New York Times articles.


“Pioneering VR”
A Film by Sebastian Sanchez

This film offers a primer on Virtual Reality through interviews with VR pioneer Tom Furness and other leaders in the field, including DeepStream VR co-founder Ari Hollander (throughout the run of Ugly Lies the Bone, audiences will be able to experience DeepStream VR’s program “Cool!” in the lobby of the Black Box Theatre). Furness (who first wanted to be an astronaut!) developed VR technology through the Department of Defense for 23 years before taking the technology outside of the military for new, public applications – for use in everything from exposure therapy to pain management to education.


“What If Pain Was a Verb?”
TEDx Bellevue

DeepStream VR’s Chief Medical Officer Alex Cahana discusses the medical field’s use of opiate painkillers and the options for safer, more sustainable pain management. To change our methods of pain management, he argues, we must also change our understanding of pain, from conceiving of it as a static symptom of injury to conceiving of it as an independent, active, and changeable state.


Ugly Lies the Bone begins plays through November 22 at our Black Box Theatre. All tickets to Roundabout Underground are general admission for only $25. For more information and tickets, please visit our website.





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2015-2016 Season, Ugly Lies the Bone

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Ugly Lies The Bone: To Read


Immerse yourself in the world of Ugly Lies the Bone with our reading list.

Brian Castnebook1r

Written by an officer who served three tours in the Middle East – two of them leading an Explosive Ordnance Disposal unit in Iraq. Castner’s experience abroad (dealing with hands-on IED disarmament) and at home (struggling with the effects of traumatic brain injury and PTSD, which he calls “The Crazy”) points to the changing face of war in the 21st century. IEDs first appeared in combat zones in 2002, and the injuries caused by their explosions (traumatic brain injury, post-traumatic stress disorder, amputations, spinal cord injuries, and burns) have demanded new advances in the fields of medicine and mental health.


Vanessa M. Gezaribook2

Gezari, a journalist, followed three American civilians sent to Afghanistan in 2008 as one faction of the Pentagon’s Human Terrain System. The HTS, a counterinsurgency effort started in 2006 and shut down in June of 2015, sent social scientists (a group that included academics, anthropologists, and retired military personnel) into combat zones in order to provide military commanders with a greater understanding of the communities they would move through in deployment. The hope was that the cultural knowledge gained through the program would result in better informed military decisions and a resultant decrease in civilian and American deaths. Gezari’s take on the controversial and expensive program (and the civilians that risked – and lost – their lives in it) offers insight into both the country of Afghanistan and the evolution of US military tactics.


“Burning Man”
Jay Kirk

This GQ profile of Army First Lieutenant Sam Brown was, in part, the inspiration for Lindsey Ferrentino’s Ugly Lies the Bone. Brown was severely burned in an IED explosion in his first tour of Afghanistan. Recovering at the Brooke Army Medical Center in San Antonio, Brown was one of the first soldiers to participate in a pioneering Virtual Reality study, which tested the effectiveness of Virtual Realty Therapy on acute pain. The program Brown used, SnowWorld, makes many appearances in Ugly Lies the Bone, as Jess attempts to get through painful physical therapy with the aid of a virtual world.


Gayle Tzemach Lemmon
Lemmon’s book tracks the women of the US Army’s Cultural Support Teams, female Army, Guard, and Reserve soldiers who joined male Special Operations units in Afghanistan. The female soldiers occupied a unique space in these missions, as they were able to search and question Afghani women in a way that their male counterparts (at least within the bounds of cultural sensitivity) could not. The book is an examination of the changing role of women in the military, particularly relevant in light of an upcoming January 2016 deadline that will allow women into combat positions in Special Ops Forces.

Ugly Lies the Bone begins plays through November 22 at our Black Box Theatre. All tickets to Roundabout Underground are general admission for only $25. For more information and tickets, please visit our website.

Related Categories:
2015-2016 Season, Ugly Lies the Bone

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