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Military Behavioral Health

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Virtual Reality as a Tool for Delivering PTSD Exposure

Therapy and Stress Resilience Training
a a a a a
Albert Rizzo , Bruce John , Brad Newman , Josh Williams , Arno Hartholt , Clarke
a a
Lethin & J. Galen Buckwalter
a
University of Southern California, Institute for Creative Technologies , Playa Vista ,
California
Published online: 12 Dec 2012.

To cite this article: Albert Rizzo , Bruce John , Brad Newman , Josh Williams , Arno Hartholt , Clarke Lethin & J. Galen
Buckwalter (2013) Virtual Reality as a Tool for Delivering PTSD Exposure Therapy and Stress Resilience Training, Military
Behavioral Health, 1:1, 52-58, DOI: 10.1080/21635781.2012.721064

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 MILITARY BEHAVIORAL HEALTH, 1: 52–58, 2013
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ISSN: 2163-5781 / 2163-5803 online
DOI: 10.1080/21635781.2012.721064

Virtual Reality as a Tool for Delivering PTSD

Exposure Therapy and Stress Resilience Training
Albert Rizzo, Bruce John, Brad Newman, Josh Williams, Arno Hartholt, Clarke Lethin,
and J. Galen Buckwalter
University of Southern California, Institute for Creative Technologies, Playa Vista, California
Downloaded by [University of Glasgow] at 22:48 06 October 2014

The incidence of post-traumatic stress disorder (PTSD) in returning Operation Enduring Free-
dom and Operation Iraqi Freedom military personnel has created a significant behavioral
health care challenge. One emerging form of treatment for combat-related PTSD that has
shown promise involves the delivery of exposure therapy using immersive virtual reality (VR).
Initial outcomes from open clinical trials have been positive, and fully randomized controlled
trials are currently in progress. Inspired by the initial success of our research using VR to
emotionally engage and successfully treat persons undergoing exposure therapy for PTSD, we
have developed a similar VR-based approach to deliver resilience training prior to an initial
deployment. The STress Resilience In Virtual Environments (STRIVE) project aims to create
a set of combat simulations (derived from our existing virtual Iraq/Afghanistan PTSD expo-
sure therapy system) that are part of a multiepisode interactive narrative experience. Users
can be immersed within challenging virtual combat contexts and interact with virtual char-
acters as part of an experiential approach for learning emotional coping strategies believed
to enhance stress resilience. This article describes the development and evaluation of the vir-
tual Iraq/Afghanistan exposure therapy system and then details its current transition into the
STRIVE tool for predeployment stress resilience training.

Keywords: PTSD, stress resilience, allostatic load, cognitive coping, virtual reality

INTRODUCTION significantly higher after duty in Iraq (15.6 to 17.1 percent)

than after duty in Afghanistan (11.2 percent) or before de-
The physical, emotional, cognitive, and psychological de- ployment to Iraq (9.3 percent)” (Hoge et al., 2004, p. 13).
mands of a combat environment place enormous stress on Reports since that time on OEF/OIF PTSD and psychoso-
even the best-prepared military personnel. The stressful ex- cial disorder rates suggest even higher incidence rates (Fis-
periences that are characteristic of the Operation Enduring cher, 2010; Seal, Bertenthal, Miner, Sen, & Marmar, 2007;
Freedom (OEF)/Operation Iraqi Freedom (OIF) war-fighting Tanielian et al., 2008). For example, as of 2010, the Mili-
environments have produced significant numbers of returning tary Health System recorded 66,934 active duty patients who
service members (SMs) at risk for developing post-traumatic have been diagnosed with PTSD (Fischer, 2010), and the
stress disorder (PTSD) and other psychosocial health con- Rand Analysis (Tanielian et al., 2008) estimated that at a
ditions. In the first systematic study of OEF/OIF mental 1.5 million deployment level, more than 300,000 active duty
health problems, the results indicated that “the percentage and discharged veterans will suffer from the symptoms of
of study subjects whose responses met the screening crite- PTSD and major depression. With total deployment num-
ria for major depression, generalized anxiety, or PTSD was bers now having increased to more than 2 million, the Rand
Analysis likely underestimates the current number of SMs
who may require (and could benefit from) clinical attention
upon the return home. These findings make a compelling
Address correspondence to Albert Rizzo, USC Institute for Creative case for a continued focus on developing and enhancing the
Technologies, 12015 East Waterfront Drive, Playa Vista, CA 90094. E-mail: availability of evidence-based treatments to address a men-
[email protected] tal health care challenge that has had a significant impact
 VIRTUAL REALITY AS A TOOL FOR DELIVERING PTSD EXPOSURE THERAPY AND STRESS RESILIENCE TRAINING 53

on the lives of our SMs, veterans, and their significant oth- treatment typically involves the graded and repeated imagi-
ers, all of whom deserve our best efforts to provide optimal nal reliving and narrative recounting of the traumatic event
care. within the therapeutic setting. This approach is believed to
provide a low-threat context where the client can begin to
confront and therapeutically process the emotions that are
VIRTUAL REALITY EXPOSURE THERAPY relevant to a traumatic event as well as decondition the learn-
ing cycle of the disorder via a habituation/extinction pro-
Concurrent with the start and progression of OEF/OIF, a cess. While the efficacy of imaginal exposure has been es-
virtual revolution has taken place in the use of virtual re- tablished in multiple studies with diverse trauma populations
ality (VR) simulation technology for clinical and training (Rothbaum, Hodges, Smith, Lee, & Price, 2000; Rothbaum
purposes. Technological advances in the areas of computa- et al., 2001; Rothbaum & Schwartz, 2002), many patients
tion speed and power, graphics and image rendering, display are unwilling or unable to effectively visualize the traumatic
systems, body tracking, interface technology, haptic devices, event. In fact, avoidance of reminders of the trauma is in-
authoring software, and artificial intelligence have supported herent in PTSD and is one of the cardinal symptoms of the
the creation of low-cost and usable VR systems capable of disorder.
running on a commodity-level personal computer. VR allows To address this problem, researchers have recently turned
for the precise presentation and control of stimuli within dy- to the use of VR to deliver exposure therapy (VRET) by
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namic, multisensory, 3D, computer-generated environments, immersing users in simulations of trauma-relevant environ-
as well as providing advanced methods for capturing and ments in which the emotional intensity of the scenes can be
quantifying behavioral responses. These characteristics serve precisely controlled by the clinician in collaboration with
as the basis of rationale for VR applications in the clinical the patients’ wishes. In this fashion, VRET offers a way to
assessment, intervention, and training domains. The unique circumvent the natural avoidance tendency by directly deliv-
match between VR technology assets and the needs of various ering multisensory and context-relevant cues that aid in the
clinical treatment and training approaches has been recog- confrontation and processing of traumatic memories without
nized by a number of scientists and clinicians, and an en- demanding that the patient actively try to access his or her
couraging body of research has emerged that documents the experience through effortful memory retrieval. Within a VR
many clinical targets where VR can add value to clinical as- environment, the hidden world of the patient’s imagination
sessment and intervention (Holden, 2005; Parsons & Rizzo, is not exclusively relied upon, and VRET may also offer an
2008; Rizzo, Parsons, et al., 2011; Riva, 2011; Rose, Brooks, appealing treatment option that is perceived with less stigma
& Rizzo, 2005). To do this, VR scientists have constructed by “digital generation” SMs and veterans who may be more
virtual airplanes, skyscrapers, spiders, battlefields, social set- reluctant to seek out what they perceive as traditional talk
tings, beaches, fantasy worlds, and the mundane (but highly therapies.
relevant) functional environments of the schoolroom, office, These ideas have been supported by three reports in which
home, street, and supermarket. Emerging R&D is also pro- patients with PTSD were unresponsive to previous imagi-
ducing artificially intelligent virtual human agents that are nal exposure treatments but went on to respond successfully
being used in the role of virtual patients for teaching clinical to VRET (Difede & Hoffman, 2002; Difede et al., 2007;
skills to novice clinical professionals (Lok et al., 2007; Rizzo Rothbaum et al., 2001). In addition, VR provides an objec-
et al., in press) and as anonymous online health care support tive and consistent format for documenting the sensory stim-
agents (Rizzo, Lange, et al., 2011). This convergence of ex- uli to which the patient is exposed that is not possible when
ponential advances in underlying VR-enabling technologies operating within the unseen world of the patient’s imagi-
with a growing body of clinical research and experience has nation. Based on this, the University of Southern Califor-
fueled the evolution of the discipline of clinical virtual re- nia Institute for Creative Technologies developed a “Virtual
ality. And this state of affairs now stands to transform the Iraq/Afghanistan” simulation that is being used in a variety
vision of future clinical practice and research to address the of clinical trials to investigate the potential for this form of
needs of both civilian and military populations with clinical treatment (see Figure 1).
health conditions. The treatment environment consists of a series of vir-
tual scenarios designed to represent relevant contexts for
VRET, including city and desert road environments. In addi-
THE VIRTUAL IRAQ/AFGHANISTAN tion to the visual stimuli presented in the VR head-mounted
EXPOSURE THERAPY SYSTEM display, directional 3D audio and vibrotactile and olfactory
stimuli of relevance can be delivered. Stimulus presentation
Among the many approaches that have been used to treat is controlled by the clinician via a separate “Wizard of Oz”
persons with PTSD, graduated exposure therapy appears to interface, with the clinician in full audio contact with the pa-
have the best-documented therapeutic efficacy (Bryant, 2005; tient. User-centered tests of the application were conducted
Rothbaum, Hodges, Ready, Graap, & Alarcon, 2001). Such at the Naval Medical Center San Diego and within an Army
 54 A. RIZZO ET AL.

FIGURE 1 Virtual Iraq/Afghanistan: “Middle Eastern City” and “Desert Road” Humvee scenarios.

Combat Stress Control Team in Iraq. This feedback from non- anxiety, and depression symptoms, and anecdotal evidence
diagnosed personnel provided information on the content and from patient reports suggested that they saw improvements
usability of our application, which fed an iterative design pro- in their everyday life. These improvements were also main-
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cess leading to the creation of the current clinical scenarios. tained at three-month posttreatment follow-up.
A detailed description of the virtual Iraq/Afghanistan system Other studies have also reported positive outcomes. Two
and the methodology for a standard VRET clinical protocol early case studies reported positive results using this sys-
can be found in other recent studies (e.g., Rothbaum, Difede, tem (Gerardi, Rothbaum, Ressler, Heekin, & Rizzo, 2008;
& Rizzo, 2008). Reger & Gahm, 2008). Following those, an open clinical
Initial clinical tests of the system have produced trial with active duty soldiers (n = 24) produced significant
promising results. In the first open clinical trial, anal- pretreatment and posttreatment reductions in PCL-M scores
yses of 20 active duty treatment completers (19 male, and a large treatment effect size (Cohen’s d = 1.17) (Reger
1 female, M age = 28, age range: 21–51) produced pos- & Gahm, 2011). After an average of seven sessions, 45%
itive clinical outcomes (Rizzo, Parsons, et al., 2011; of those treated no longer screened positive for PTSD, and
Mclay et al., 2012). For this sample, mean pre- 62% had reliably improved. Three randomized controlled
and post-PTSD Checklist—Military Version (PCL-M; trials (RCTs) are ongoing using the virtual Iraq/Afghanistan
Blanchard, Jones-Alexander, Buckley, & Forneris, 1996) system with active duty and veteran populations. Two RCTs
scores decreased in a statistical and clinically meaningful are focusing on comparisons of treatment efficacy between
fashion: from 54.4 (SD = 9.7) to 35.6 (SD = 17.4). Paired VRET and prolonged imaginal exposure (PE) (Reger &
pre- and post-t-test analysis showed these differences to be Gahm, 2010; Reger et al., 2011) and VRET compared with
significant (t = 5.99, df = 19, p < .001). Correcting for VRET plus a supplemental care approach (Beidel, Frueh, &
the PCL-M no-symptom baseline of 17 indicated a greater Uhde, 2010).
than 50% decrease in symptoms; 16 of the 20 completers no A third RCT (Difede, Rothbaum, & Rizzo, 2010–2013) is
longer met PCL-M criteria for PTSD at posttreatment. Five investigating the additive value of supplementing VRET and
participants in this group with PTSD diagnoses had pretreat- imaginal PE with a cognitive enhancer called D-cycloserine
ment baseline scores below the conservative cutoff value of (DCS). DCS, an N-methyl-d-aspartate partial agonist, has
50 (pretreatment scores = 49, 46, 42, 36, 38) and reported been shown to facilitate extinction learning in laboratory
decreased values at post treatment (posttreatment scores = animals when infused bilaterally within the amygdala prior
23, 19, 22, 22, 24, respectively). Mean Beck Anxiety In- to extinction training (Walker, Ressler, Lu, & Davis, 2002).
ventory (BAI; Beck, Epstein, Brown, & Steer, 1988) scores The first clinical test in humans that combined DCS with
significantly decreased 33%, from 18.6 (SD = 9.5) to 11.9 VRET was performed by Ressler and colleagues (2004) and
(SD = 13.6), (t = 3.37, df = 19, p < .003) and mean Patient included participants diagnosed with acrophobia (n = 28).
Health Questionnaire (PHQ-9; Kroenke and Spitzer, 2002) Participants who received DCS with VRET experienced sig-
(depression) scores decreased 49% from 13.3 (SD = 5.4) to nificant decreases in fear within the virtual environment one
7.1 (SD = 6.7), (t = 3.68, df = 19, p < .002). The average week and three months posttreatment, and they reported sig-
number of sessions for this sample was just under 11. Re- nificantly more improvement than the placebo group in their
sults from uncontrolled open trials are difficult to generalize overall acrophobic symptoms at three-month follow-up. This
from, and we are cautious not to make excessive claims based group also achieved lower scores on a psychophysiological
on these early results. However, using an accepted military- measure of anxiety than the placebo group. The current mul-
relevant diagnostic screening measure (PCL-M), 80% of the tisite PTSD RCT will test the effect of DCS versus placebo
treatment completers in the initial VRET sample showed both when added to VRET and PE with active duty and veteran
statistically and clinically meaningful reductions in PTSD, samples (n = 300).
 VIRTUAL REALITY AS A TOOL FOR DELIVERING PTSD EXPOSURE THERAPY AND STRESS RESILIENCE TRAINING 55

THE STRESS RESILIENCE IN VIRTUAL system and aims to foster stress resilience by creating a set
ENVIRONMENTS (STRIVE) APPROACH of combat simulations that can be used as contexts for the
experiential learning of cognitive-behavioral emotional cop-
The current urgency in efforts to address the psychologi- ing strategies in SMs prior to deployment. This will involve
cal wounds of war in SMs and veterans has also driven an immersing and engaging SMs within a variety of virtual
emerging focus within the military on emphasizing a proac- missions where they are confronted with emotionally chal-
tive approach for better preparing SMs for the emotional lenging situations that are inherent in the OEF/OIF combat
challenges they may face during a combat deployment to re- environment. Interaction by SMs within such emotionally
duce the potential for later adverse psychological reactions challenging scenarios will aim to provide a more mean-
such as PTSD and depression. This focus on stress resilience ingful context in which to learn and practice psychoedu-
training prior to deployment represents no less than a quan- cational and cognitive coping strategies that are believed to
tum shift in military culture and can now be seen emanating psychologically prepare them for combat deployment. To
from the highest levels of command in the military. For ex- accomplish this, STRIVE is being designed as a 30-episode
ample, in an American Psychologist article, General George interactive narrative in VR, akin to being immersed within
Casey (2011) of the U.S. Army makes the case that “soldiers a Band of Brothers-type story line that spans a typical de-
can ‘be’ better before deploying to combat so they will not ployment cycle. At the end of each of the graded 10-minute
have to ‘get’ better after they return” (p. 1), and he then calls episodes, an emotionally challenging event occurs, designed
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for a shift in the military “to a culture in which psychological in part from feedback provided by SMs undergoing PTSD
fitness is recognized as every bit as important as physical treatment (e.g., seeing/handling human remains, death/injury
fitness” (p. 2). This level of endorsement can be seen in of a squad member, the death/injury of a civilian child). At
practice by way of the significant funding and resources ap- that point in the episode, the virtual world “freezes in place”
plied to stress resilience training within the Comprehensive and an intelligent virtual human “mentor” (selected by the
Soldier Fitness program (Cornum, Matthews, & Seligman, user) emerges from the midst of the chaotic VR scenario to
2011). The core aim of such approaches is to promote psy- guide the user through stress-related psychoeducational and
chological fitness and better prepare service members for the self-management tactics, as well as provide rational restruc-
psychological stressors that they may experience during a turing exercises for appraising and processing the virtual
combat deployment. experience. The stress resilience training component draws
Resilience is the dynamic process by which individu- on evidence-based content that has been endorsed as part of
als exhibit positive adaptation when they encounter signifi- standard classroom-delivered DOD stress resilience training
cant adversity, trauma, tragedy, threats, or other sources of programs, as well as content that has been successfully ap-
stress (McEwen & Stellar, 1993). The Department of De- plied in nonmilitary contexts (e.g., humanitarian aid worker
fense (DOD) has focused significant attention on this area training, sports psychology, and other areas).
with a variety of programs being developed for this purpose In this fashion, STRIVE provides a digital “emotional
across the branches of the military (Hovar, 2010; Luthar, obstacle course” that can be used as a tool for providing
Cicchetti, & Becker, 2000). Perhaps the program that is at- context-relevant learning of emotional coping strategies un-
tempting to influence the largest number of SMs is the afore- der very tightly controlled and scripted simulated conditions.
mentioned Comprehensive Soldier Fitness (CSF) program Training in this format is hypothesized to improve general-
(Cornum et al., 2011). This project has created and dissem- ization to real-world situations via a state-dependent learning
inated training that aims to improve emotional coping skills component (Godden & Baddeley, 1980) and further support
and ultimate resilience across all Army SMs. One element resilience by leveraging the learning theory process of latent
of this program draws input from principles of cognitive- inhibition. Latent inhibition refers to the delayed learning
behavioral science, which generally advances the view that that occurs as a result of preexposure to a stimulus without a
it is not the event that causes the emotion but rather how a consequence (Feldner, Monson, & Friedman, 2007; Lubow
person appraises the event (based on how he or she thinks & Moore, 1959). Thus, exposure to a simulated combat con-
about the event) that leads to the emotion (Ortony, Clore, text is believed to decrease the likelihood of fear conditioning
& Collins, 1988). From this theoretical base, it then follows during the real event (Sones, Thorp, & Raskind, 2011).
that internal thinking or appraisals about combat events can
be “taught” in a way that leads to more healthy and resilient
reactions to stress. This approach does not imply that people STRESS BIOMARKERS
with effective coping skills do not feel some level of rational AND ALLOSTATIC LOAD
emotional pain when confronted with a challenging event
that would normally be stressful to any individual. Instead, The STRIVE project also incorporates a novel basic science
the aim is to teach skills that may assist soldiers in an effort protocol. While other stress resilience projects incorporate
to cope with traumatic stressors more successfully. one or two biomarkers of stress and or resilience, the STRIVE
The STRIVE (STress Resilience In Virtual Environments) projects will measure what we refer to as the physiological
project has evolved from the virtual Iraq/Afghanistan VRET fingerprint of stress, commonly called allostatic load (AL).
 56 A. RIZZO ET AL.

The theoretical construct of AL, initially developed by one cal processes, including appraisal of and reactions to various
of the STRIVE collaborators, Bruce McEwen, is a measure stressors—for example, resilience—may constitute a sepa-
of cumulative wear and tear on physiological symptoms due rate but interdependent subsystem in the allostatic model.
to chronic stress (McEwen & Stellar, 1993). As a theoretical We support a case-based approach to analysis, which ac-
construct, it is a preliminary attempt to formulate the re- knowledges that each allostatic system is unique in its con-
lationship between environmental stressors and disease, by figuration based on differences in (1) environmental context,
hypothesizing mechanisms whereby multiple kinds of stres- including the user’s socioeconomic status and the availabil-
sors confer risk simultaneously in multiple physiological sys- ity of psychosocial resources; (2) regulation and plasticity
tems. The construct of AL is based on the widely accepted of bioallostatic systems; (3) regulation and plasticity of what
response called allostasis. Sterling and Eyer (1988) defined we term psychoallostatic systems; (4) psychology, includ-
allostasis as the body’s set points for various physiological ing personality and appraisal of stressors; (5) environmental
mechanisms, such as blood pressure or heart rate, which vary stressors, which range from biological to sociological; and
to meet specific external demands, for example, emotional (6) health outcomes. AL will be measured via the devel-
stress. McEwen and Stellar (1993) furthered our understand- opment and integration of complex biomarkers known to
ing of allostasis by broadening its scope. Rather than discuss indicate physiological dysfunction, and normal function, for
allostasis in terms of a single set point that changes in re- numerous physiological systems (including immune, cardio-
sponse to a stressor, they describe allostasis as the combina- vascular, metabolic).
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tion of all physiological coping mechanisms that are required In a first study of its kind, we will determine whether
to maintain equilibrium of the entire system. Thus, allosta- AL can predict acute response to stress (using EEG, GSR,
sis is the reaction and adaptation to stressors by multiple ECG, pupil dilation, etc.), when participants are exposed to
physiological systems that brings the system back to equi- the stressful VR missions. Further analyses will determine
librium. The related concept of homeostasis refers specifi- whether AL can predict participants’ responses to virtual
cally to system parameters essential for survival (McEwen, mentor instructions on how the participants can cope with
2002). To place AL into the context of allostasis, allostasis stress through stress resilience training. If we find that AL is
does not always proceed in a normal manner. Any of the capable of predicting either short-term response to stress or
major physiological systems—inflammatory, metabolic, im- the ability to learn stress resilience, there would be numerous
mune, neuroendocrine, cardiovascular, and respiratory—can implications for the future use of AL, including identification
in the process of responding to stress exact a cost, or an allo- of leadership profiles and informing the development of ap-
static load, that may result in some form of physiological or propriate training systems for all SMs. Pilot research on this
psychological disturbance. McEwen (2000) identified four project is ongoing at the Immersive Infantry Training Center
types of AL: (1) frequent activation of allostatic systems; (2) at Camp Pendleton, California.
prolonged failure to shut off allostatic activity after stress;
(3) lack of adaptation to stress, and (4) inadequate response
of allostatic systems leading to elevated activity of other, CONCLUSIONS
normally counterregulated allostatic systems after stress, for
example, inadequate secretion of glucocorticoid, resulting in The STRIVE program is designed both to create a VR ap-
increased cytokines normally countered by glucocorticoids. plication for enhancing SM stress resilience and to provide
Any of these types of AL interfere with the normal stress a highly controllable laboratory test bed for investigating
response of allostasis, thus increasing AL. This will increase the stress response. Success in this area could have signif-
one’s risk for disease in the long term and may preclude the icant impact on military training and for the prevention of
short-term development of physical hardiness and psycho- combat stress–related disorders. Another option for use of
logical resilience. the STRIVE system could involve its application as a VR
From a conceptual standpoint, the construct of AL is still tool for emotional assessment at the time of recruitment to
undergoing development. More recent AL models posit the the military. The large question with such an application in-
interaction of biomarkers on multiple levels. Juster, McEwen, volves whether it would be possible (and ethical) to assess
and Lupien (2009) theorize that by measuring multisystemic prospective SMs in a series of challenging combat-relevant
interactions among primary mediators (e.g., levels of cortisol, emotional environments delivered in the STRIVE system to
adrenalin, noradrenalin) and relevant subclinical biomarkers predict their potential risk for developing PTSD or other
representing secondary outcomes (e.g., serum high-density mental health difficulties based on their verbal, behavioral,
lipoprotein [HDL] and total cholesterol), one can identify in- and physiological/hormonal reactions recorded during these
dividuals at high risk of tertiary outcomes (e.g., disease and virtual engagements. To use such information for recruitment
mental illness). Yet we argue this approach does not fully decisions would require a change from the apparent doctrine
encapsulate the dynamic, nonlinear, evolving, and adaptive that anyone can be made into infantry personnel. However,
nature of the interactions between these biomarkers. More- practical implementation of such an approach could advise
over, these markers are not purely physiological. Psychologi- that those who display reactions predicting they will be most
 VIRTUAL REALITY AS A TOOL FOR DELIVERING PTSD EXPOSURE THERAPY AND STRESS RESILIENCE TRAINING 57

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