The Virtual Iraq/Afghanistan system uses exposure therapy to help service members deal with traumatic events, such as IED explosions or the death of a comrade. (Institute for Creative Technologies)
Train the brain: It’s a recurring mantra for the training and simulation industry, but it has never been more pertinent than for veterans struggling with post-traumatic stress disorder. Adapting existing technology to clinical needs isn’t necessarily new — but it is picking up speed and a variety of options.
One of the rising stars is virtual reality, which is moving from game controllers and low-fi graphics to molded resin replicas of guns and goggles displaying first-rate worlds. There, troops can travel back to their traumatic events and work through the thoughts that still haunt them.
The U.S. Department of Veterans Affairs estimates that between 11 percent and 20 percent of service members who serve in Iraq or Afghanistan develop PTSD. Symptoms include hyperarousal (sleep problems, difficulty concentrating, irritability), reliving the traumatic event, nightmares, alcohol or drug abuse, and avoiding social situations.
One therapeutic PTSD tool, the Virtual Iraq/Afghanistan program, is in place in close to 50 hospitals and clinics across the U.S. The system offers a variety of scenarios. With the smell of gunfire and body odor in the air, troops can drive along a desert road only to have their Humvee hit an improvised explosive device. Or they can walk the town as the call to prayer rings in their ears, passing a spice market only to hear gunfire break out. It will never replicate the traumatic event a service member had in the war zone, but it doesn’t have to.
“With virtual reality, you are limited by the technology,” said Michael Kramer, a clinical psychologist who uses the Virtual Iraq/Afghanistan program through VA. “You can’t re-create that exact occurrence, but you can help trigger a memory.”
The virtual reality system builds on exposure therapy, a widely accepted method for treating PTSD. Typical exposure therapy asks the service member to verbally describe the traumatic event, often in excruciating detail. For those who have difficulty remembering the event or constructing a narrative, Kramer said, virtual reality provides wiggle room.
“That’s the real value of the technology,” Kramer said. “The technology affords us a flexibility that other things can’t. If they aren’t buying that it’s Iraq, we can try something else. We can try the scent of burning rubber or the sound of machine-gun fire.”
The Virtual Iraq/Afghanistan systems in use today still run on the original Gamebryo game engine that they were first developed with in 2003. However, researcher Albert “Skip” Rizzo, who worked with colleagues at the Institute for Creative Technologies (ICT) at the University of Southern California to develop the virtual reality program, said the upgraded version of the system should start rolling out by the end of summer.
Researchers received a grant to rebuild the system with the Unity game engine, vastly improving the quality. New versions will have increased resolution; improved shadowing, lighting and physics within the world; greater diversity of scenarios such as caves, decaying buildings and remote outposts; and more Afghan-centric content.
Kramer said programs like Virtual Iraq/Afghanistan are not more commonly used because of a combination of cost and availability.
“When it starts getting more attention and more popularity and it starts getting cheaper and people can start finding it in their local communities, more and more people will use it,” Kramer said.
Although increased graphics and options will certainly make the simulation more realistic, Rizzo emphasizes that the basis of the therapy is in the scientific research and results behind it. Exposure therapy works effectively, and the data are just starting to trickle in for virtual reality therapy.
“People think technology is going to fix somebody,” Rizzo said. “But you can’t just throw technology at a problem and expect that by its mere presence, it’s going to be better. You have to look at what we know in the real world and track that knowledge into the digital world.”
Exposure therapy, virtual or not, isn’t a solution for all PTSD cases, said Paul Cummings, senior fellow at ICF International, a Fairfax, Va.-based consulting firm. Reliving the events may be too traumatic or stressful. But for veterans suffering from PTSD-related nightmares, he and other researchers have been developing another virtual technology.
Power Dreaming provides a simple interface that patients use to create and populate their own worlds. The available scenery is full of peaceful rivers and idyllic woodlands, to which users can add a variety of animals or avatars. There is even the option to scan in faces of friends and family, which are then applied to avatars and imported into the landscape. By the time the veteran is done designing, he or she will have created a happy place that evokes an “epic win” feeling.
When veterans awaken from a nightmare, the therapy asks them to go through some relaxation and breathing exercises, then flip on the head-mounted display. There, they can walk or fly through their world, experiencing and interacting with a space where they are in complete control.
The technique relies on neuroplasticity, which is the brain’s ability to rewire itself — in this case, in response to stress. By repeatedly teaching the body to calm down and feel in control after a nightmare, veterans can potentially reduce the chaos and fear they feel.
“Being able to directly impact and deal with nightmares can add value to their quality of life,” Cummings said.
Power Dreaming is still in the development stage, but Cummings says the project should be approved to start testing subjects this summer, with data and analysis coming shortly after.
PTSD tools are not constrained to a set of goggles or a head-mounted display; several tools are available through virtual worlds accessed via the Internet. SimCoach is an interactive program with four different avatars that users can talk with about PTSD. The coach can give the user an assessment, suggest local care facilities, give information about the disorder, and offer an anonymous place to talk.
“It’s not a doc in the box,” said John Hart, program manager for ICT at the Army Research Lab. “It’s not going to diagnose you with PTSD. But it’s going to provide you some information and maybe some encouragement to hold some further conversations that you wouldn’t normally do because there might be a stigma attached.”
Alternatively, veterans can log in (again, anonymously) to a Second Life online virtual world and interact with other veterans’ avatars. At the peaceful, if virtual, Chicoma Lodge, people can talk or access therapeutic activities. This Transitional Online Post-deployment Soldier Support in Virtual Worlds program, also known as “Coming Home,” tries to fill the role of 20th-century Veterans of Foreign Wars halls.
“People can come together. It’s just a place to talk to somebody else who may have been through similar experiences,” Hart said. “It may be therapeutic to be able to tell your own story.”
Virtual reality programs — whether they rely on goggles or laptops — all face the same struggle when trying to provide proper levels of realism. Users are aware that they are looking at something computer-generated, and programs that try for complete realism may tumble instead into the “uncanny valley” — where not-quite-perfect human avatars can be off-putting.
“You don’t want to make it 1950s Buck Rogers,” Cummings said. “You have to draw a balance. You need something you can feel engaged with, but there’s an imagination component that fills in the blanks.”
Staying a Step Ahead
Coping with PTSD after the fact isn’t the only method researchers are trying. Researchers at ICT, again led by Rizzo, are putting together a training program that prepares troops’ minds before they ever set foot in combat.
The program is called Stress Resilience in Virtual Environments, or STRIVE. Rizzo envisions an interactive, “Band of Brothers”-type narrative of 30 episodes, each one building a relationship between the viewer and the characters. You’ll get to know them all: the courageous leader, the goofball, the shy guy.
Then, at the end of every episode, something bad happens. “With TV, you might not want to do that,” Rizzo joked.
When the traumatic event occurs — an explosion, attack or death — a virtual mentor walks out on screen. The mentor will teach troops immediate tips and tactics to deal with the stress, such as deep breathing. In addition to coping tips, the goal is to give troops pre-exposure to stress.
“It leverages latent inhibition,” Rizzo said. “If you expose somebody to something in a controlled environment in advance, when they face that challenge in the real world, there’s less chance of fear conditioning — which is at the base of PTSD.”
ICT is currently working on three episodes, each of a different intensity. These are scheduled to be tested at Camp Pendleton, Calif., during the summer.
“We want to get these folks early on and teach them emotional coping tactics so we can insulate them from later development of PTSD,” Rizzo said.
Mobile Brain Train
One reason why clinicians have switched to virtual reality is to attempt to entice the younger generation of digital natives returning from war.
“Not everybody can come in to the clinic. We have a big problem with barriers to care,” Rizzo said.
However, for ease of access, nothing beats the mobile device already sitting in many service members’ pockets. Using a mobile app is private, relatively anonymous, free and totally at the service member’s convenience.
There are many PTSD apps available, but with limited research and scientific testing, most clinicians are hesitant to call them treatments. Rather, they are tools.
Kramer, for example, recommends the PTSD Coach, an app by the National Center for PTSD. The app has a learning section to teach users about PTSD and professional care, a 17-question assessment and history function to track symptoms, crisis resources and a way to set up personalized emergency contacts, and a management tool that suggests solutions depending on how the user feels.
If a veteran were angry, it might suggest a deep-breathing exercise or a distraction, such as organizing a bookshelf. If the user feels disconnected, it might pop up advice on changing perspective or a pleasant event suggestion such as playing tennis. And if one suggestion doesn’t appeal, the “New Tool” button is waiting to be pushed in the lower right-hand corner.
The National Center for Telehealth and Technology (T2) collaborated with the National Center for PTSD to make the app, but it also provides several other free mobile tools for PTSD sufferers. Breathe2Relax is a customizable stress management program that guides users through breathing exercises with animation and spoken instructions.
T2 also produces the MoodTracker app, where users can rank how they feel on a sliding scale and track their progress over time. The categories are specific. Veterans can rate their anxiety, depression, general well-being, stress or post-traumatic stress, each with close to a dozen sub-categories. Examples include ranking how social, hopeful, numb, angry or relaxed users feel.
Some apps, such as PTSD Support by Hope for One, provide new social networks where veterans can discuss their feelings on a Facebook-style platform.
“That can be exceptionally helpful, but it can also be problematic,” Kramer said.
The trouble stems from uncertainty about getting good advice or support from strangers, a problem that could also exist in virtual reality programs that rely on avatars.
Nevertheless, Kramer advocates using apps, virtual reality or even gaming as a way to build a community, lessen the feeling of isolation, and connect with others. Even playing something like the commercial “Call of Duty” video games can make veterans feel more connected — but it shouldn’t be misconstrued as treatment, nor should treatment be miscategorized as a form of entertainment.
“All games are simulations, but not all simulations are games,” Rizzo said.
With the realization that many service members are coming back with PTSD or traumatic brain injury, organizations have also started creating training technology for families of veterans. Veterans suffering from anger, depression or isolationist tendencies can add strain to their relationships as they attempt to transition back to civilian life. The VA says that veterans with PTSD are more likely to have marital or relationship issues, and “rates of divorce for veterans with PTSD were two times greater than for veterans without PTSD.”
In response, VA worked with Kognito Interactive to create Family of Heroes, an online game meant to teach veterans and family members how to manage expectations and communicate successfully. Launched in November, the program is still rolling out, although it already has 33,000 users, according to Ann Feder, a mental health care line program manager for VA. A controlled trial of 120 veterans and supporters conducted through the VA hopes to gather data on how successful the program is and should return results on the program by the end of summer.
In the simulation, users guide three families through conflict de-escalation, choosing from several options on what their character should say. Issues addressed are ones that many families face: talking about financial issues, confronting someone about isolation or alcohol abuse, or dealing with triggers that set off a loved one. A friendly female animation guides users through tactics for managing their own feelings and ways to stay calm despite stressful interactions.
“It’s not treatment,” Feder said. “It’s training.”
Characters in the interactive scenarios look more like cartoons than some of the realistic avatars in other programs, but Feder has interviewed many of the veterans and family members who have tried the program.
“I didn’t get one person that said the avatars feel phony,” she said. In this program, content is king.
Feder also says that the platform is adaptable. There is potential for creating more unique characters or adding conversations as the program expands and receives more feedback.
As a generation of troops return from war, increased training to cope with what they have experienced is essential. Researchers suggest the technology will only get better, citing potential improvements in voice recognition, more intelligent artificial intelligence, more realistic emotional and cognitive interaction with virtual worlds, and increased access from home.
“Expect to see exponential growth in quality and speed and facility,” Rizzo said.
Within the next year, researchers should accumulate mountains of data about how the more technological approach to PTSD is working, which will either confirm or refute the anecdotal evidence of success. Despite the different approaches, all attempt to change how veterans think about their traumatic experiences, rewiring their brains so that they learn to cope with triggers and responses to stress. The knowledge gained from treating and training veterans may eventually help those with PTSD from other traumatic events, such as rape or abuse.
“The driver is war,” Rizzo says. “War sucks. But every damn war has driven innovation and advances in medicine, rehabilitation and mental health.”