He was in the HUMVEE, and all he could see was blood and dust. What happened? “Jim, where are you? Jim?Jim, can you hear me?” But he did not hear an answer. After a few seconds, he realized what had happened, the HUMVEE had hit an explosive. As the dust started to settle, he finally saw his best friend slumped next to him, dead. All of a sudden, he wakes up sweating and screaming. His wife lying next to him tries to comfort him, but even though the nightmare is over, its contents still haunt him because he saw it happen, in real life. This is the life of someone with post-traumatic stress disorder (PTSD) and an experience that might be displayed on a headset during a virtual reality exposure therapy (VRET) session to treat the PTSD (Smith 2010).
Virtual reality exposure therapy is a breakthrough treatment for combat-related PTSD. PTSD is caused by exposure to trauma, such as the death of friends or killing people in combat. PTSD is characterized by reliving the traumatic event, sleep disturbances, excessive anger or inability to control emotions, and avoidance of triggers (“DSM Criteria for PTSD”). Many veterans suffer from PTSD due to their combat experiences, especially those who have served in Iraq or Afghanistan. Estimates show that up to 18 percent of returning soldiers from Iraq and Afghanistan develop PTSD (Rothbaum et al. 2010). Effective treatment is desperately needed, and VRE is one that is being researched and shows significant promise.
Virtual reality technology has been identified for treatment for PTSD because it seems real enough to be used for exposure therapy and is relatively easy to operate. It started out as a project called Virtual Iraq which is viewed by a mounted headset. Virtual Iraq has desert and city scenes that a United States soldier in Iraq is likely to experience such as “desolate streets, checkpoints, ramshackle buildings, warehouses, mosques”, etc. (Rizzo et al. 2010). Animated people can be added or taken away from the scenes. The most useful part to clinicians is that certain scenarios that each individual patient needs for the experiences that traumatized them the most can be used (Rizzo et al. 2010). The clinician can change what the patient sees, hears, smells, and feels to make the virtual reality as close to the real experience as possible. Weather conditions and lighting can be changed. Sounds such as gunfire and voices can be added. Fans can blow in scents such as smoke or garbage, and even vibration can be inserted (Rizzo et al. 2010). So, a patient whose traumatic experience was the death of a fellow soldier can relive that experience with a clinician to work through the emotions that the experience brings (Rizzo et al. 2011).
The virtual reality has been tested for how realistic it is by soldiers without PTSD, and it was determined to be mostly realistic. The audio was rated as more realistic than the visual components. The virtual reality headgear was said to not be much of a hindrance. Also, any negative feedback was attempted to be fixed. For example, some mentioned that a simulated weapon would be more realistic, and without one, many of the soldiers were distracted. So, a simulated weapon was added (Rizzo et al. 2010).
As for soldiers’ willingness to use VRE therapy, a study showed that some soldiers are actually more willing to participate in technologically based treatments than traditional therapy which is important because those soldiers will get the treatment that they otherwise would not get. This study showed that most soldiers have access to computers and internet. Most soldiers were willing to take part in traditional and technological therapy. However, 33 percent were willing to take part in the technologically based therapies that were not willing to take part in the traditional therapies. This is likely because of location and/ or fear of the stigma associated with treatment (Wilson 2008). Another similar survey found that 20 percent of soldiers who were unwilling to participate in traditional therapy were willing to use the virtual reality treatment (Rizzo et al. 2010). The stigma associated with treatment seems to be especially important. A study on perceived stigma in Marines found that “many soldiers and Marines believe that receiving mental health services would cause them to be seen as weak (65%), be treated differently by unit leaders (63%), lose confidence of their peers (59%), or be blamed for their problems (50%), or that their careers would be harmed” (Momen et al. 2012). These soldiers may seek VRET though because it can be done anonymously. So, these findings are important because it means that some soldiers may get treated for their PTSD that otherwise may not have looked for help.
The effectiveness of VRE therapy is also being studied, and it is being shown to be relatively effective even compared to traditional therapy. Traditional exposure therapy consists of education, breathing, practice, and talking about the trauma. Traditional exposure therapy includes imagining the trauma and allowing the anxiety associated with that to subside. The therapist works with the soldier to change their reactions to the traumatic memories and triggers associated with them. Each session lasts about 90 minutes, and there are between 8 and 15 sessions (Prolonged Exposure Therapy 2009). VRET works similarly in that all of the stages are included, but the practice stage consists of virtual reality instead of imagining the trauma. This is especially important because some soldiers who have had longer or multiple deployments struggle to imagine the trauma for the extended period of time that is required for exposure therapy, but with the virtual reality, they are able to continue to think about and relive the trauma for the duration of the session so that they can be treated (Smith 2010). This is what makes VRET often more effective than traditional exposure therapy.
In one study of the effectiveness of VRE treatment, there was a statistically significant decrease in PTSD symptoms; in fact, 16 out of 20 of the people who completed the program did not meet the criteria for PTSD anymore (Rizzo et al. 2010). In another study, 45 percent of participants no longer had PTSD symptoms, and 62 percent had symptom reduction. This same study showed that virtual reality therapy had better results than traditional therapy (Rizzo et al. 2011). In another study which was a meta-analysis of a few studies, it was shown that VRET was relatively effective especially compared to control groups (Goncalves et al. 2012). While more research on the issue will be occurring in the future, VRET is definitely already being shown to be effective.
Though the cost of VRET is initially high, it is worth it because of the benefits. If it cannot be used easily or cost-effectively, then it will not be readily accessible to the veterans who need it. However, it appears that it is quite possible for it to become a viable treatment. The cost of the headwear system is $1500 which is reasonable since it can be used for many patients, and each clinician would only need one (Rizzo et al. 2010). Also, the technology aspect of VRE means that it can be more widely used and may be more widely accepted because soldiers who do not live near a Veterans Affairs (VA) treatment center or who fear the stigma associated with treatment can receive treatment through the technology and possibly even anonymously (Rizzo et al. 2011). Additionally, the United States Army Medical Research and Materiel Command is funding a study by the Department of Defense to determine how effective VRET is. This study could potentially lead to the widespread usage of VRET in VA treatment centers. In fact, VRET is already being used in medical centers in San Diego, Washington D.C., and Hawaii and some VA hospitals because it is already being revealed to be effective (Smith 2010). If VRET expands to include most VA centers or becomes available anonymously, many soldiers would have easier access to treatment that they need and would be more likely to use it.
Combat-related PTSD is a major problem for returning soldiers. Many are still affected by traumas they experienced months or years later. Treatment for PTSD is definitely needed. VRET is becoming a viable option and is already in use in many places, and it should become a leading effective treatment for combat-related PTSD.
Works Cited “DSM Criteria for PTSD.” United States Department of Veteran Affairs. US Department of Veteran Affairs, 5 July 2007. Web. 3 Apr. 2013.
Gonçalves, R., Pedrozo, A., Freire Coutinho, E., Figueira, I., & Ventura, P. (2012). Efficacy of Virtual Reality Exposure Therapy in the Treatment of PTSD: A Systematic Review. Plos ONE, 7(12), 1-7.
Momen, N., Strychacz, C. P., & Viirre, E. (2012). Perceived Stigma and Barriers to Mental Health Care in Marines Attending the Combat Operational Stress Control Program. Military Medicine, 177(10), 1143-1148.
Prolonged Exposure Therapy (2009, September 29). In United States Department of Veteran Affairs. Retrieved April 9, 2013
Rizzo, A., Difede, J., Rothbaum, B. O., Reger, G., Spitalnick, J., Cukor, J., & Mclay, R. (2010). Development and early evaluation of the Virtual Iraq/Afghanistan exposure therapy system for combat-related PTSD. Annals Of The New York Academy Of Sciences, 1208(1), 114-125.
Rizzo, A., Parsons, T., Lange, B., Kenny, P., Buckwalter, J., Rothbaum, B., & … Reger, G. (2011). Virtual Reality Goes to War: A Brief Review of the Future of Military Behavioral Healthcare. Journal Of Clinical Psychology In Medical Settings, 18(2), 176-187.
Rothbaum, B. O., Rizzo, A., & Difede, J. (2010). Virtual reality exposure therapy for combat-related posttraumatic stress disorder. Annals Of The New York Academy Of Sciences, 1208(1), 126-132.
Smith, L. (2010, January 19). Virtual Reality Exposure Therapy to combat PTSD. In The Official Homepage of the United States Army. Retrieved April 9, 2013
Wilson, J. B., Onorati, K., Mishkind, M., Reger, M. A., & Gahm, G. A. (2008). Soldier Attitudes about Technology-Based Approaches to Mental Health Care. Cyberpsychology & Behavior, 11(6), 767-769.