Playing Through the Pain

On paper, Virtual Iraq sounds like the greatest war game ever made.

You put on the binocular headset, and you’re instantly transported behind the wheel of a dusty Humvee. Yours is the second vehicle in a convoy, and as you bounce along the city streets, you uneasily scan the alleyways and rooftops for insurgents. The rumble of the engine vibrates your sweaty flesh. You smell gasoline, body odor and the faint traces of Iraqi cooking (someone must be making dinner nearby). Over the hum of fighter jets and helicopters, you hear the echoing call to evening prayers.

Suddenly, a rocket streaks toward you, and the Humvee in front of yours explodes, billowing smoke and orange flame. As you scramble for cover, your nose is filled with the rank smell of burning rubber and gunpowder. Shots ring out behind you, but they’re hard to hear over the screams of civilians fleeing the explosion.

Virtual Iraq may be the most realistic and detailed war simulator to date, but it is no ordinary videogame.

The program is an innovative therapeutic tool, designed to help thousands of veterans suffering from posttraumatic stress disorder. By immersing themselves in a virtual Iraq, soldiers can confront their worst combat memories head on, to deal with their trauma and reconcile their fears.

Posttraumatic stress disorder (PTSD) is a complex cocktail of anxiety, fear and helplessness that results from exposure to life-threatening events, such as military combat. Sufferers will do anything to avoid situations or cues that remind them of the trauma they’ve experienced. “The root of PTSD is unprocessed emotional memories,” says Skip Rizzo, a clinical psychologist at the University of Southern California. “Those memories come out at night, in nightmares and flashbacks.”

Military personnel – particularly combat veterans – are especially susceptible to PTSD. A study published in the July 1, 2004 issue of The New England Journal of Medicine revealed that one out of every eight Iraq war veterans has the disorder. (That study was conducted back when the war was relatively new; current estimates place the rate as high as 20 percent.)

But PTSD remains a taboo subject in many military circles. Oftentimes, soldiers are concerned that if they seek therapy, they risk contempt or ostracism from their peers and commanding officers. Only 40 percent of the Army veterans from the Iraq war who tested positively for mental disorders in the study actually sought medical care; rates were even lower among veterans of combat operations in Afghanistan.

Stigma is just one reason veterans avoid therapy; the therapy itself is another big factor. One of the most effective PTSD treatment methods is “imaginal exposure therapy,” or confronting trauma through a set of guided, systematic recollections. Therapists repeatedly walk patients through their most painful memories, asking clients to imagine, describe and discuss the traumatic event. As time progresses, patients grow less anxious and more confident with their feelings and memories. “It’s almost brain-dead simple, this idea that the more you’re exposed to something, the more you get used to it,” says Rizzo. But this “touchy feely” style turns off many grizzled, combat-hardened veterans.

Moreover, traditional exposure therapy has its limits. Barbara Rothbaum, an assistant professor of psychology at Emory University, has been using exposure therapy for years to treat anxiety disorders, but she says that the PTSD mental block is hard to crack. “Even in the first study we did, some of the people said they knew what they needed to do, but there was no way they could bring themselves to do it,” says Rothbaum. “People with PTSD are pretty avoidant.”

Rothbaum started exploring alternative methods for exposure therapy over 10 years ago, when she and Larry Hodges at Georgia Tech experimented with virtual reality to treat the fear of heights and planes. They discovered that the virtual reality therapy worked just as well as traditional exposure therapy did, and soon, Rothbaum started researching its use for other anxiety disorders, such as PTSD.

Many people still see virtual reality as a parody of itself; the goofy headsets and trippy virtual environments have inspired fads like the Virtual Boy and B-movies like The Lawnmower Man. But as a therapy tool, virtual reality has proven exceptionally potent. “We found that people do get better using virtual reality therapy,” says Rothbaum. “That it translates into real life.”

Rothbaum points out another benefit of virtual reality: “If you think about who the Iraq war veterans are, it’s a very video-savvy, electronic generation,” she says. “For people who don’t want traditional therapy, the idea of virtual reality might be attractive. They might get curious and try it.”

Virtual imaginal exposure therapy works much like the real-world version does, but instead of recreating a patient’s memories in his mind, his experiences are replicated in a digital environment. Wearing a binocular headset, the patient traverses the virtual world using a game controller. The therapist guides her through that artificial environment, tweaking stimuli and environmental details according to the patient’s specific memories. To keep track of anxiety levels, the patient gives a Subjective Units of Discomfort reading every five minutes, rating her emotional distress from 0-100. As the patient grows comfortable, the therapist includes more stress-inducing stimuli into the virtual world.

In 1997, Rothbaum’s company, Virtually Better, worked with Rizzo and designer Jarrell Pair to develop the first virtual reality treatment specifically designed for veterans with PTSD. That application, Virtual Vietnam, was a simple program that allowed patients to enter a virtual Huey helicopter and fly over two locations: a rice patty and a clearing surrounded by jungles. What they found was that although the graphics were primitive, patients didn’t seem to care. “People would come out of the simulation, and they’d tell you these elaborate stories about how they ran to the helicopter when the Vietcong came out of the jungle,” says Rizzo. “That wasn’t in the environment. People filled in the gaps themselves.”

Rothbaum explains that it’s the PTSD that inspires patients to make up the missing details. “As long as you tap into some of their fears and get people anxious, they will fill in the rest,” she says. The approach proved to be a surprising success. A 2006 paper in the Journal of Clinical Psychiatry reported that after six months, 78 percent of the Vietnam veterans who used Virtual Vietnam for therapy had improved mental functioning, opposed to 50 percent who’d used other methods.

Virtual Iraq is the spiritual successor to Virtual Vietnam, although the application is generations ahead of its predecessor in both capability and design. For example, Virtual Iraq features several environments, including a small village, a large city, checkpoints and a Humvee convoy. The therapist also has far more control over environmental stimuli, everything from weather patterns and time of day to the volume and variety of ambient sounds. The graphics, too, are much improved: Virtual Iraq is based off Full Spectrum Warrior, a commercially released console game originally intended to train Army officers.

Virtual Iraq goes beyond the audio-visual experience, tapping into other sensory organs. Into the simulation, Rizzo has introduced a vibration mechanism that rumbles the platform upon which a patient sits or stands so as to match explosions in the virtual world. Also, Rizzo’s team has built a smell box that pumps up to eight distinct scents into patients’ noses, including body odor, burning rubber, gunpowder and rotting garbage. “Smell is a key ingredient here, because sense of smell is directly connected to the limbic system, which is responsible for memory,” says Rizzo.

Imprint Interactive, a virtual reality technology company based out of Seattle, has also developed a number of applications for soldiers with PTSD, collaborating with the Army, Veterans Administration and the Office of Naval Research. But the company has also worked extensively to bring virtual therapies to civilians grappling with PTSD. Imprint helped modify a simulation of the 9-11 World Trade Center attacks built by the University of Washington and, more recently, worked with Israel’s University of Haifa to develop a bus bomb simulator.

Like Virtual Iraq, Imprint’s bus bombing simulation scales in intensity. Clinicians can control several different factors: noise levels, AI reactions, siren sounds, intensity of the bus explosions, etc. It is entirely customizable. “There’s a fine line between getting patients to clear the air around their memories and re-traumatizing them,” says Ari Hollander, technical director at Imprint Interactive. “You want to gradually reintroduce people to their memories.”

Virtual reality exposure therapy is still a new technique, and no paradigms or precedents exist for therapists who want to use it for treatment. From technical design to graphical realism, everything about these applications is mostly trial and error. “All of these things are not well understood,” says Hollander. “One of the main goals of our research is to find what does and doesn’t work.”

But experimentation is costly and slow. Advances in virtual reality technology have been sluggish, and equipment prices are still prohibitively high. Moreover, few people are involved with the research. “We have people who wear a lot of hats,” says Hollander, who does 3-D modeling, sound engineering, scripting, coding, web design and hardware configuration. “I’m constantly running around in little circles, trying to get everything to work.”

He adds that one of the biggest challenges facing developers is the design of a user-friendly interface for psychologists and clinicians, who tend to be technology-averse. “Therapists don’t know anything about technology. Frequently, they don’t even know anything about computer games,” says Hollander. “So you have to make this bizarre, exotic hardware as simple as possible to use.” This means that the very flexibility that makes virtual reality so attractive as a therapeutic tool becomes a liability in terms of programming and design. The challenge becomes finding a happy medium between flexibility and ease-of-use.

Virtual Iraq has currently entered the clinical testing phase, with research groups running trials and pilot programs across the country. At Emory, Rothbaum is currently examining the effectiveness of combining virtual reality therapy with medication. In her study, PTSD patients take a pill approximately thirty minutes before engaging in four sessions of virtual exposure therapy. One group takes D-cycloserine, a drug that reduces fear symptoms; another takes Xanax, a common anti-anxiety medication; and a third takes a placebo pill. The hope is that drugs will prove to be a useful complement to the virtual reality.

Imprint’s bus bomb simulation has also entered the clinical testing phase, but finding appropriate respondents has been difficult. “They had a bunch of trouble in Haifa getting a population of patients who were compatible,” says Hollander. “They kept getting patients who were the absolute worst-case scenario, and so nothing worked on them.”

Rizzo, Rothbaum and Hollander all agree that good feedback is hard to find, but it’s the most critical element in designing these applications. “You can’t design these things from the ivory tower,” says Rizzo. “You need that feedback on what you’ve gotten right and wrong to drive your work.”

But where do you draw the line between reality and virtual reality? How realistic should these applications strive to be? Rizzo admits that the limits are still hazy. He mentions that people have requested he add the smell of burning or rotten flesh to his smell box, and logically, he can see the reasoning. “When somebody’s gone through the whole thing, and you think they just need that one last experience to really pull out that emotion and deal with it, then maybe that’s when you hit that button.

“But what is the smell of death?” he asks uncomfortably. I don’t know how to answer that question, either. “I mean, I smelled a dead cat once, and I almost puked. The smell of rotting human – I – I don’t know. I’m not sure how far up the hierarchy of exposure we really need to go.”

Although Rizzo asserts that a therapist should do whatever is necessary to help the patient, he argues that realism by itself isn’t the point of virtual reality therapy. “No matter what, we’re not going to exactly replicate and eradicate any memories of what has happened here,” he says. “But how they deal with the pain, that changes how it impacts their life. We’re just helping someone to heal.”

Lara Crigger is a freelance science and tech journalist specializing in electronic entertainment. Her previous work for The Escapist includes “Escaping Katrina” and “The Milkman Cometh.” Her email is lcrigger [at] gmail [dot] com.