TRAINING AND SIMULATION
To Heal Psychological Trauma, Troops Relive War in Virtual Reality
The roadside bomb exploded. A shaker table beneath him simulated the shock wave. High-tech speakers blasted the sound of AK-47 fire around him.
Turning the head to the right revealed that his companion was seriously injured. Blood oozed from his wounds.
Although the software was adapted from a computer simulation designed for war fighters heading overseas, this program is aimed at those returning from battle.
Virtual Iraq, developed at the University of Southern California’s Institute for Creative Technologies, is one of two programs being used by the U.S. military to help victims overcome the sometimes debilitating effects of post traumatic stress disorder.
“It’s based on the idea that fear burns itself out,” said Lt. Cmdr. Robert McLay, a psychiatrist at the Naval Medical Center in San Diego, and the service’s primary investigator of virtual reality systems used to treat PTSD.
“If you tell the story over and over again, the story no longer becomes fear provoking. It becomes boring.”
This method is called exposure therapy. And although there is some disagreement in the mental health community as to the best way to treat the disorder, most clinicians practice this method.
Traditionally, the therapists will ask the patient to think back and recreate the traumatic scene that led to the disorder in his or her mind’s eye.
“It’s a tall order to imagine in detail the things that are haunting them,” said Skip Rizzo, research scientist at the institute, and co-creator of the program.
Virtual Iraq is intended to be a tool for a well-trained clinician experienced in treating post traumatic stress disorder, he said.
“We’re not going to erase someone’s memories … that’s not what this is about. This is about dealing with the anxiety, getting it out, and over time going to where the anxiety structure, the fear structure gets out of the brain and no longer haunts you.”
McLay said the military and the U.S. Department of Veterans Affairs has seen an increasing number of patients suffering from PTSD since the beginnings of the wars in Afghanistan and Iraq.
A Rand Corp. research brief, “Invisible Wounds: Mental Health and Cognitive Care Needs of America’s Returning Veterans,” said 18.5 percent of U.S. service members who have returned from Afghanistan and Iraq suffer from post traumatic stress disorder.
Roughly half of them do not seek treatment, and only half of those who do “get minimally adequate care,” said the brief.
PTSD has been around since man first took up arms, said McLay. One of the first described cases in literature was Achilles in Homer’s The Iliad.
From the Civil War to World War II, the condition had many names — “battle fatigue” and “shell shock” are two. In World War I, sufferers risked receiving a dishonorable discharge for suffering battlefield stress.
Treatment for what became known as PTSD became more enlightened and refined in the mid-1980s as the condition affected many Vietnam War veterans.
“Unlike physical wounds, these conditions affect mood, thoughts, and behavior and often remain invisible to society,” the Rand report said.
Left untreated, sufferers have a higher risk of engaging in unhealthy behaviors such as drinking, smoking, unprotected sex and have higher suicide rates.
Not everyone who has been through a traumatic event suffers from PTSD. Immediately after an event, just about everyone will have similar symptoms, Rizzo said. It’s normal to lose sleep, and replay the scene over and over in the head in the days and weeks after an event. Most people soon let these feelings go.
“Everyone would test [positive] for PTSD the day after. Over time, you get over it,” Rizzo said.
For others, the symptoms remain. Months later, they feel as bad or worse about the incident as the day it happened.
The Rand report said, “these conditions can impair relationships, disrupt marriages, aggravate the difficulties of parenting and cause problems in children that may extend the consequences of combat trauma across generations.”
The good news is that if the condition is treated with some of the proven therapy methods, the victims can go on to lead productive lives, McLay said.
“People sometimes think it’s there for life. With good treatment you can recover from this. You can go back to work, and you can go back to your family,” he said.
“It doesn’t change the fact that something bad happened,” he continued. “You can’t change the fact that war is a horrible thing, but they can get back to where they are functional and they can get back to normal lives.”
McLay has used both Virtual Iraq as well as a similar PTSD treatment tool created by Virtual Reality Medical Center, a Palo Alto, Calif.-based company.
The Navy is wrapping up safety and efficacy studies on both. “We know that both sets of software are useful. Both have their advantages and disadvantages,” McLay said.
Virtual Iraq tends to be more for the “trigger pullers” — those who experienced trauma in combat. Virtual Reality Medical Center has other scenarios for non-combat personnel such as construction engineers and medical workers.
Rizzo said one of the features of Virtual Iraq is that the patient and the therapist can collaborate to come up with scenes that simulate the incident that led to the trauma.
There are mounted and dismounted scenarios. When in a humvee, the patient can sit in a chair with the goggles on. If there is an explosion the shaker table simulates the bomb blast.
He can stand and carry a weapon while on a foot patrol through a crowded marketplace. The therapist can adjust the sounds, weather and time of day. The institute is also introducing smells into the mix to heighten the realism. Although he stressed that the simulation doesn’t have to be an exact replica of what they experienced for it to work.
In a typical treatment, the therapist and patient would not use virtual reality during the first few meetings. Then they might start slowly, maybe with just the patient driving down a road without any roadside bomb or ambush at all.
McLay said, “It adds a level of control to the therapy that wasn’t there before.”
As the therapy progresses, and the patient repeats the scenario several times, “the story no longer becomes fear provoking, it becomes boring,” McLay said.
The mental health field has been experimenting with virtual reality since the mid-1990s, McLay noted. There have been Virtual Vietnams, a World Trade Center scenario for those who have lived through 9/11, and Virtual Reality Medical Center offers computer programs for those suffering from fear of flying.
One way to treat these conditions is “in vivo” or by taking the patient into a real-life situation. Virtual Reality Medical Center’s flight simulation program is touted as a less expensive way to perform this therapy, which would otherwise require the therapist and patient to buy plane tickets.
Of course, desensitizing someone who is suffering from battle-related PTSD is never going to happen “in vivo,” McLay pointed out.
Safety issues have been addressed, he added. There were some initial concerns that patients would be overwhelmed by the experience — that it would be too realistic, and this might worsen their condition. But that wasn’t the case.
And a first round of studies has shown that virtual reality therapy for PTSD is effective, he noted. He has taken the Virtual Reality Medical Center to Iraq and observed progress in patients himself.
“What’s really not demonstrated is that it’s worth the time and the money,” McLay said.
The traditional way, where therapist and patient talk out the scenario, is obviously cheaper and doesn’t require expensive software or equipment such as shaker tables.
“If you did the talk therapy, would you get just as good results with a lot less money and effort?” McLay asked.
Can virtual reality speed up the treatment process? That also has not been scientifically proven, he said.
The Navy is funding several comparative studies to determine if virtual reality-based therapy tools perform better than traditional methods.
Simply showing a picture of a scene on a view screen might be just as effective, he said.
These comparative studies take time and he expects it will be more than two years before the mental health community begins to see definitive answers.
As for adding stimuli such as smells to the mix, answers as to whether that is anymore effective, is “years away” McLay said.
Meanwhile Virtual Iraq is being used at about 20 sites, including several V.A. hospitals.
“We’re fighting and struggling every day for funding,” Rizzo said.
But there is widespread acknowledgement that PTSD is a problem that needs to be addressed. “Now there is a bright spotlight out on it,” Rizzo said.
The Rand report, while not addressing virtual reality-based treatment, said more can be done to help PTSD victims in the military receive higher quality care. Further investment in research is needed, it said.
“Medical science would benefit from a deeper understanding of how these conditions evolve over time among veterans as well as the effect of treatment and rehabilitation on outcomes,” Rand said.
The report also urged the military to conduct a better public information campaign to make military personnel aware that they may have a problem. The macho warrior ethos makes some reluctant to seek help or acknowledge that they have a problem in the first place, McLay said.
“One of the biggest problems we face is getting people to come in for treatment,” he said.
Rizzo added, “War sucks but the one thing we will get from this is that we will evolve our treatment tools…. [War] does drive innovation in medical, mental health and rehabilitation.”