Healing the Invisible Wounds of War with Virtual Reality

Veterans in America is a special limited-series podcast from RAND.

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By Stephanie O'Neill (@ReporterSteph)

It was called “shell shock” in World War I. In World War II, it was known as “battle fatigue” and “combat exhaustion” and caused as many as half of all military discharges during World War II, according to the Department of Veterans Affairs.

But it wasn't until 1980 that America's mental health community formally recognized this invisible wound of war as post-traumatic stress disorder (PTSD).

The RAND Corporation's Invisible Wounds of War study estimates that as many as one in five who've seen battle experiences PTSD, which—if left untreated—can rip apart lives with nightmares, flashbacks, insomnia, anger, guilt, and feelings of isolation.

Since 9/11, nearly three million service members have deployed to war zones in Iraq and Afghanistan—about half of them more than once.

Now, an innovative, evidence-based approach to treating PTSD is reaching more veterans than ever before. Called “virtual reality exposure therapy,” it heals by transporting the veteran back to the traumatic war event, into a computer-generated, parallel universe created in a Southern California lab.

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Visit the University of Southern California Institute for Creative Technologies and you're likely to bump into a motorcycle-riding, Ugg-wearing psychologist, renowned for his research into medical virtual reality therapy.

His name is Skip Rizzo, and among his specialties is the treatment of PTSD among U.S. service members and veterans.

On a recent afternoon, Rizzo invites me to check out some of his work here at the Playa Vista, Calif. facility, a Department of Defense-sponsored University Affiliated Research Center that works in collaboration with the U.S. Army Research Laboratory.

So, I put on a pair of virtual reality goggles and headsets and land inside an Afghan village—my heart racing as the sights and sounds of war explode before me.

In my arms, Rizzo places a faux rifle that has no bullets. Instead, when I pull the trigger, it speeds my passage through this computer-generated war-scape. When I want to change course, I aim the rifle's barrel and I'm sent in a new direction.

I lose time here in virtual Afghanistan and find it hard to remember that none of this is real—that it's all happening inside a pair of virtual reality goggles and headsets I'm wearing here in the institute's medical virtual reality unit, which Rizzo directs.

“We can make characters pop out of this palm grove and start firing at you. We can have explosions way off in the distance,” Rizzo said, creating a far-off audio blast with a tap of his keyboard. “Or we can bring it on in.”

This close-up explosion he clicks to life sends sound waves vibrating through four subwoofers set under the elevated platform I'm standing on.

A few more keyboard strokes and Rizzo fattens the audio with frantic voices, automatic weapon fire, overhead helicopters, and military radio calls he uploads into the scene with a desktop computer.

A Medical Virtual Reality Pioneer

Rizzo's been at forefront of innovations in this field since the mid-1990s. The software he's demonstrating is called Bravemind, and it's now used at more than 100 clinical sites, including U.S Department of Veterans Affairs hospitals, military bases, and several universities.

To understand how it works to heal PTSD, Rizzo says you must first understand a bit about something called “exposure therapy,” which has been around for a few decades.

“The traditional method, someone with PTSD goes to a clinician's office,” Rizzo said. “The clinician then says, 'OK, I want you to close your eyes, and I want you to narrate one of your experiences,' and usually they categorize them from the least aversive to the most. 'And start off with the least averse: I want you to go to that event that happened while you were driving the Humvee, and I want you to close your eyes and imagine you're in it now and talk about it, describe it as if you're going through it now.'”

So, the veteran does that, out loud. Then the therapist has them repeat the story several times, adding more detail with each telling in order to unearth more memories. When it's done using just a person's memories, it's called “imaginal exposure therapy.”

When virtual reality is introduced, it's like adding steroids.

The goal, Rizzo said, is twofold: excavate as much of the veteran's anxiety as possible and then extinguish it.

Even for non-veterans, the experience is intense, said Terri Tanielian, a senior behavioral scientist with the RAND Corporation.

“Having sat and participated in a virtual reality therapy, it is kind of really overwhelming in that it does give you that very, very real experience,” Tanielian said.

And that is exactly why it works so well, said Rizzo.

“It sounds like torture at first, but it's the best evidence-based approach for treating PTSD, this trauma-focused approach,” said Rizzo. “Eventually, as you do this repeatedly, the anxiety dissipates quicker and the anxiety doesn't go up as high.”

A Life Changing Day

“August 20th, 2004 in Mosul. That was a life-changing day for me,” said former Marine and Army National Guard soldier, Joe Merritt.

That was the day a 100-pound improvised explosive device (IED) exploded in front of the Humvee he was driving.

“And if they had waited 10 more seconds, I wouldn't be here,” he said. “I would have been frickin' in a soup sandwich and somebody would have put me in a bucket because there wouldn't have been anything left.”

As it was, the vehicle in front of his took most of the hit. Merritt and his crew rescued the soldiers who safely fled that vehicle as flames engulfed it. But as he tried driving everyone to safety, his Humvee wouldn't budge.

“It was runnin', but it was not going anywhere,” he said. “It's like the transmission was in neutral, and you know everything's on fire... So, it's getting pretty damn hot, and we can't get anyone on the radio because the radio is just going nuts.”

In the haze of smoke and heat, Merritt and his men were taking on artillery fire. And just when it seemed there was no escape, the Humvee transmission sputtered back to life and Merritt drove the soldiers to safety.

“(I) had not smoked a cigarette in five years prior to that moment,” he said. “I smoked six in 30 minutes, and I smoked every day for the rest of the time I was in country, as well as chewed tobacco.”

“I Knew Something Was Wrong”

Back home in South Carolina, Merritt's wife Sonya had no idea what had happened. But during a Skype call, she noticed the cigarette.

Joe and Sonya Merritt

Joe and Sonya Merritt

Merritt family photos

“I knew something was wrong when I saw the cigarette in his hand,” Sonya said.

Merritt, a father of four and a veteran with a dozen years of service, was no stranger to combat. He joined the Marines as a 19-year-old and fought in the first Gulf War.

“I participated in Desert Shield with the build-up,” he said, “and participated as ground fighting forces during the invasion of Kuwait in the liberation of Kuwait.”

But the man who came back from that war was different from the man who came back from post-9/11 Iraq. Sonya says he was irritable, quick to react, and hyper-vigilant. She and the kids found themselves walking on eggshells.

“We could just say the wrong thing,” she said. “If I was gone and didn't text him back right then, he would think something happened to me.”

Turns out the IED blast sent him home with both PTSD and a traumatic brain injury. Then, an incident he doesn't speak about publicly, one that involved hand-to-hand combat—worsened the PTSD. For about 10 years, Merritt tried to just live with the symptoms.

“There's been so many times where I've exploded,” he said. “I've jerked people out of cars I've thrown s‐‐‐ through the walls. I've lost it. There have been times I've been curled up in that corner with a shotgun.”

But then a fellow veteran told him about PTSD help provided by the Warrior Care Network. That's a partnership between the nonprofit Wounded Warrior Project and four of the nation's top academic medical centers.

Among them: Emory School of Medicine in Atlanta.

A Clinical Virtual Reality Pioneer

Clinical psychologist Barbara Rothbaum heads the Emory Healthcare Veterans Program. She is renowned for three decades of pioneering work in applying virtual reality treatments to PTSD and other anxiety disorders.

Among the challenges of healing PTSD, she says, is something psychologists call “avoidant behavior.” It's a way many of us cope with trauma.

“They don't want to think about it. They don't want anything to remind them of it,” she said. “Sometimes they can talk about it seemingly pretty easily. But then what I notice is that they've cut themselves off from their emotions, and so that's part of PTSD, too. We call it 'emotional numbing.'”

For them, Rothbaum says, traditional exposure therapy doesn't work so well, because the only way to heal emotional trauma is to fully experience it.

“I make a lot of analogies to the grief process: when someone we love dies, it's very painful,” she says. “But by being around other people that loved them, by crying, by experiencing the pain, we get through it. So maybe six months down the road we still miss them; it's still painful, but it's not as intensely painful. Maybe we can talk about them without crying.”

But asking combat veterans to dig into those painful emotions their combat training teaches them to bury isn't easy. And the longer they've kept emotions under lock and key, the less likely traditional exposure therapy will work.

A Treatment Game-Changer

Rothbaum was the first to test virtual reality exposure therapy on veterans. She did that in the late 1990s with Vietnam combat vets who were considered treatment-resistant.

“We wanted to see would the virtual reality… have anything to offer them—as another treatment alternative. And it did. They got better,” said Rothbaum. “They've reported that it didn't bother them anymore, these experiences that have been haunting them for decades.”

Joe Merritt and his two dogs, Trigger and Zeke, in Joe's woodworking workshop

Joe Merritt and his two dogs, Trigger and Zeke, in Joe's woodworking workshop

Photo by Stephanie O'Neill

Rothbaum and Rizzo are colleagues who spent the last two decades leading the study, testing, and development virtual reality software to treat military PTSD.

Skip Rizzo's group at USC, which gets funding from the U.S. military and private donors, has been developing Bravemind for nearly 15 years. Today, the virtual reality system offers up a number of wartime scenarios that match nearly any combat experience conjured up by a post-9/11 vet.

“Our first version only had four worlds,” Rizzo said. “So, we got a lot of feedback from clinicians working to treat people: Do you have an Afghan village? Do you have a remote mountain outpost? We didn't have that.”

The first iterations of Bravemind date back to 2004—a time, Rizzo said, when few believed PTSD would be as big an issue as it turned out to be.

“In fact, we had applied to NIH (National Institutes of Health) for funding,” he said. “And one of the reviewers had the audacity, or ignorance or whatever to say, 'We don't think that there's going to be a problem like with Vietnam. We don't even know if this would get used.'”

For Joe Merritt, and many of the vets accepted into the treatment at Emory each year, the emotional excavation does more than just reduce anxiety and PTSD symptoms. It also helps veterans understand what actually happened in combat, and that the story they've been telling themselves for years or even decades may not be accurate.

“A lot of people feel guilty about their behavior, what they did to survive, what they didn't do,” said Rothbaum. “And by going through it in that much detail a lot of times... patients come to the realization: I don't know what else I could have done—the insurgent planted that IED so we wouldn't see it. There were a lot of eyes on the road. It wasn't just me. I did everything I could, and it sucks, but it wasn't my fault.”

Helping to Save Lives

Joe Merritt's wife, Sonya, credits the intensive treatment he underwent at Emory with helping save his life.

“He realizes now that he's not a monster and that he can cope with everyday life,” Sonya said.

He's also far less irritable with the family, with neighbors, with strangers.

“And now he knows how to just turn and walk away instead of adding fuel to the flame,” she said. “We don't have to walk on eggshells as much—I'm not going to say it's a complete cure, but he does think about what he says now before he says it or before he does something.”

Merritt said the Emory program restored a sense of calm and worth to his life and relationships that he thought was forever lost. And now whenever he meets veterans struggling with PTSD, he urges them to consider the program. He lets them know it's free to vets—travel expenses, hotel, and food—all in exchange for some hard but worthwhile personal work.

“The virtual reality is scary, but at the same time, when you come through it, it's like a breath of fresh air,” Merritt said. “It's like you know, 'Yeah, I went to boot camp, and I survived.' So, you got to kind of put it in that mentality that you're going to get through it. It's going to end, and now you're going to have tools to fall back on to try to make that situation better than it would have been prior to exposure and virtual reality therapy.”

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