REVIEW ARTICLE

Virtual Reality Applications for Stress Management

INTRODUCTION: Stress Management Training programs are increasingly being adopted in the military field for resilience empowerment
and primary stress prevention. In the last several years, advanced technologies (virtual reality in particular) have been
integrated in order to develop more innovative and effective stress training programs for military personnel, including
soldiers, pilots, and other aircrew professionals. This systematic review describes experimental studies that have been
conducted in recent years to test the effectiveness of virtual reality-based Stress Management Training programs
developed for military personnel. This promising state-of-the-art technology has the potential to be a successful new
approach in empowering soldiers and increasing their resilience to stress.
METHODS: To provide an overview from 2001 to 2016 of the application of virtual reality for Stress Management Training programs
developed for the military, a computer-based search for relevant publications was performed in several databases.
Databases used in the search were PsycINFO, Web of Science (Web of Knowledge), PubMed, and Medline. The search
string was: (“Virtual Reality”) AND (“Military”) AND [“Stress Training” OR (“Stress Management”)].
RESULTS: There were 14 studies that met the inclusion criteria and were included in the review.
DISCUSSION: The main observation to be drawn from this review is that virtual reality can provide interactive Stress Management
Training to decrease levels of perceived stress and negative affect in military personnel. This technology appears to be a
promising tool for assessing individuals’ resilience to stress and for identifying the impact that stress can have on
physiological reactivity and performance.
KEYWORDS: stress management training, virtual reality, military.

Pallavicini F, Argenton L, Toniazzi N, Aceti L, Mantovani F. Virtual realtiy applications for stress management training in the military. Aerosp Med Hum Perform. 2016;
87(12):1021–1030.

M
ilitary forces perform complex and stressful activities psychological (e.g., fear, risk of injury or death, time pressure,
wherein several emotional and cognitive factors heavy workload, uncertainty, and information overload).14,50,72
come into play. War is perhaps one of the most chal- Interestingly, in recent years increased attention has been
lenging situations that an individual can experience, and the given to programs for enhancing psychological resilience—the
challenges are exacerbated by the multifaceted, changeable, process of coping with or overcoming exposure to adversity or
and ambiguous contemporary operating space.59,73 The physi- stress6,85—and specific training programs have been developed
cal, emotional, cognitive, and psychological demands of to support military personnel, such as soldiers16 and warfighters.41,80
a combat environment place enormous stress on even the Guidelines have been developed to deal with combat stress,3,12,13
best-prepared military soldiers15,37,79 and aircrew profession-
als, such as warfighters19,55,58 and helicopter pilots.28 Moreover, From the Centre for Studies in Communication Sciences CESCOM, Department of
Human Sciences for Education “Riccardo Massa”, University of Milano-Bicocca, Milan,
stress can reduce operational effectiveness,37,50,53 flight per- Italy, and the Leonardo-Finmeccanica Airborne & Space Division, Rome, Italy.
formance,28,81 and even lead to major psychological disorders, This manuscript was received for review in February 2016. It was accepted for publication
including posttraumatic stress disorder (PTSD),1,30,60 anxiety, in September 2016.
and depression.8,33 Address correspondence to: Federica Pallavicini, Department of Human Sciences for
Education “Riccardo Massa”, University of Milano-Bicocca, Piazza Dell'Ateneo Nuovo 1,
In a military context, stressors can come in a variety of 20126 Milano. Italy; [email protected].
forms, including physical (e.g., extreme heat or lighting, lack Reprint & Copyright © by the Aerospace Medical Association, Alexandria, VA.
of sleep, dehydration, and impaired nutritional status) and DOI: 10.3357/AMHP.4596.2016

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including coping strategies to implement before deployment In recent years the use of virtual reality (VR) has been
to a combat zone, during deployment, and when returning extended to different traditional SMTs, including SIT and RT
home.72 programs.29,56,61 SIT programs have been recently implemented
Although few, if any, individuals are likely to be completely in cyber-interventions (cyber-SIT), which through advanced
immune to the effects of stress on performance, there are inter- technologies recreate simulations to teach individuals how to
vening variables known as “moderators” that can reduce the effectively cope with psychological stress.70,79,86 With respect to
performance decrement caused by stress.37 One of the most RT, VR can help stressed or anxious individuals acquire effec-
studied and most effective moderators is training.27 Stress train- tive coping skills, such as relaxation strategies29,31,61 and bio-
ing can help military personnel handle emotional and physio- feedback training.55,57,71
logical responses to stressors in order to maintain optimum By definition, VR is an application that lets users navigate
performance even in situations of high stress.25,37,44 and interact with a three-dimensional computer-generated (and
In psychiatric literature, the term “Stress Management computer-maintained) environment in real-time.62 Research
Training” (SMT) is not a single and selective concept. Most studies have compared the efficacy of VR in inducing an emo-
approaches usually contain elements of both relaxation and tional response with that of other media and/or real-life reac-
cognitive coping skills for preventing and managing stress.18 In tions, reporting that exposure to virtual stimuli produces
general, SMT can be defined as the application of any set of emotional and behavioral responses similar to those that occur
techniques (e.g., relaxation, biofeedback, and cognitive behav- in the real world.32,45 In addition, VR has recently been proven
ioral therapy) with the intent to improve the way people cope able to elicit emotions related to complex real-life stressors.56,57
with stress.4 Most research on the effects of SMT programs In the military field, the use of VR for SMT is increasingly
focuses on two main types of training: Stress Inoculation Train- common.16,66,76 Until a few years ago this technology had been
ing (SIT) and Resilience Training (RT). While SIT programs used in a military context almost exclusively for the treatment
aim to build stress tolerance through exposure, RT programs of disorders associated with exposure to stressful situations,
teach stress management techniques. especially PTSD23,24 and for flight simulation.3,5,46
SIT was born from clinical psychology as a cognitive- VR has become a topic of increasing interest to the military
behavioral treatment47–49 to help individuals cope with the because it simulates highly stressful and complex scenarios in a
consequences of being exposed to stressful events. In the mili- safe environment. In addition, this technology is customizable,
tary field, the purpose of SMT programs is to repeatedly expose dynamic, and less expensive than other methods.42,66,67
soldiers to specific stressors and ask them to perform a target In the current review we will describe experimental studies
task while under the stress. Hence, SIT can gradually lessen an that have been conducted since 2001 to test the effectiveness of
individual’s physiological response to a stimulus by reducing its VR-based SMTs developed for military personnel in order to
novelty.27 Through training, individuals may also learn how to show how this emerging state-of-the-art approach can improve
manage uncertainty22,69 and maintain high levels of perfor- soldiers’ resilience to stress.
mance despite its presence.19,33,60 Several military programs
incorporate SIT techniques. Examples include: 1) Survival,
Evasion, Resistance and Escape (SERE),26,82,83 which provides METHODS
U.S. military personnel, U.S. Department of Defense civilians,
and private military contractors with training in survival skills, We followed the Preferred Reporting Items for Systematic
evading capture, and the military code of conduct; and 2) Men- Reviews and Meta-Analysis (PRISMA) guidelines.51
tal Readiness Training (MRT),84 which was developed for the To provide an overview of VR-based SMT programs devel-
Canadian Armed Forces. oped for military personnel, a computer-based search for rele-
Resilience training (RT), i.e., the instruction of stress coping vant publications was performed in several databases. Databases
mechanisms while in a nonstressful setting, has been shown to used in the search were PsycINFO, Web of Science (Web of
reduce subjective stress assessments and increase performance Knowledge), PubMed, and Scopus. The search string was:
of individuals.26,64,74 While the term “resilience” is conceptual- (“Virtual Reality”) AND (“Military”) AND [(“StressTraining”)
ized in a number of different ways in the academic literature, OR (“Stress Management”)].
the term broadly refers to an individual’s capacity to maintain a To avoid the risk of bias, PRISMA recommendations for
functional equilibrium or display positive adaptation following systematic literature analysis have been strictly followed. Three
or in spite of risks to normal development or psychological authors independently selected paper abstracts and titles,
health.7 Some of the most important programs developed in analyzed the full papers that met the inclusion criteria, and
this area are the Comprehensive Soldier & Family Fitness Pro- resolved any disagreements through consensus. The articles
gram (CSF2, U.S. Army),20,34,64 designed to build resilience and were individually scanned to examine whether they fulfilled
enhance the performance of soldiers, their families, and U.S. the following inclusion criteria: 1) research article; 2) provide
Army civilians, and the Army’s Resilience Training Program information about the used sample; and 3) provide informa-
(Battlemind Training, U.S. Army),2,17 built as an integration of tion about measures.
resiliency training for support populations throughout existing In the current systematic review, we aimed to analyze exper-
soldier, leader, and unit strengths. imental studies (from 2001 to 2016) focused on the use of VR

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for SMT programs geared toward military personnel to provide participants who learned coping techniques during the VR
crucial indications for future studies and interventions. To this training generally enjoyed the environment and experienced
end, several aspects of the selected studies will be fully reviewed little to no discomfort while navigating within the environ-
and discussed: 1) participants; 2) experimental design; 3) type ment. Comparative analyses indicated that the virtual environ-
of task used; and 4) the main outcomes for each study. ment did increase levels of posttreatment anxiety and dysphoria.
In a second study, the same author78 investigated the use-
fulness of a cyber-SIT program to increase levels of stress in
RESULTS medical military personnel. Sixty-three volunteers who were
attending a combat medical class (e.g., Flight Medic, Joint
The flow chart of the systematic review is shown in Fig. 1. Our En-route Care Course, Ranger First Responder) were placed
initial search in PsycINFO, Web of Science (Web of Knowl- in groups to practice combat medical skills with virtual scenar-
edge), PubMed, and Scopus yielded 76 nonduplicate cita- ios only, relaxation techniques only, both, or neither. Higher
tions. After the application of the inclusion criteria, 20 articles levels of hostility were observed in the VR group than in the
remained. A deeper investigation of the full papers resulted in rest. Also, participants practicing relaxation techniques while
the exclusion of another 6 articles. In the end, only 14 studies exposed to the virtual scenarios showed higher levels of
met the full criteria and were included in this review. sensation-seeking. Interestingly, further analyses showed higher
The first important application of VR-based SMT programs levels of both anxiety and dysphoria in those previously
for the military is cyber-interventions (cyber-SIT) programs, deployed who participated either in the VR or the relaxation
developed to expose soldiers to high-stress situations in order group. Results suggested that exposure to VR scenarios involv-
to improve their responses and performance under stress ing medical skills could be a promising way to prepare soldiers
(Table I). for combat stress.
In the first study, Stetz et al.77 tested 25 soldiers (first respond- Some years later, Hourani et al.35 conducted a controlled
ers or “medics”) with VR training that consisted of a virtual pilot study to compare the efficacy of a cyber-SIT program
environment being shown while the soldiers performed tasks called PRESIT with Combat and Operational Stress Control
in a stressful combat casualty environment. Participants were (COSC),18,68 the current best practice. The purpose of the study
divided into four groups: virtual scenarios only, relaxation tech- was to use a Multimedia Stressor Environment (MSE) to induce
niques only, both, or neither. Participants received feedback on a psycho-physiological arousal response during a simulated
their psychological and physiological stress levels and practiced training mission and to assess the ability of participants to
coping strategies (e.g., combat breathing). Results showed that respond quickly and accurately to visual stimuli presented
during the mission. The MSE
(a moderate-sized Iraqi village
developed as a virtual scenario)
was presented to a viewing group
of 20 participants. Results showed
that participants with deploy-
ment experience demonstrated
improvement, which was mea-
sured as greater relaxation dur-
ing the MSE when it was shown
again in a follow-up session. In
addition, participants with more
PTSD symptoms showed more
capability for improvement, as
was true for participants who
were more anxious about their
next deployment.
Four other papers have recently
reported on experimental stud-
ies conducted during a 5-yr
partnership between the Depart-
ment of Psychiatry and Combat
Stress (DP&CS) at the Military
Institute of Medicine in Warsaw
with the Virtual Reality Medical
Center (VRMC) of San Diego.
Fig. 1. The flow chart of the systematic review. The training program consisted

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Table I. Information About the Selected Studies on VR-Based Stress Inoculation Training Programs.
VIRTUAL STRESS
STUDY SAMPLE DESIGN CONDITION(S) INOCULATION TRAINING OUTCOMES
Stetz et al. (2007)77 25 soldiers Between subjects Four conditions Combat Medic Scenario; Participants who learned
design Individual training coping techniques during
the VR training enjoyed the
environment, and
experienced minor to no
discomfort while navigating
within the environment
Stetz et al. (2008)78 63 soldiers Between subjects Four conditions Combat Medic Scenario; Exposure to VR scenarios
design Individual training where to practice medical
skills could be a promising
way to prepare warfighters
for combat stress
Hourani et al. (2011)35 77 marines Between subjects Two conditions: PRESIT; Participants with deployment
design 1) VR-based training group (EG); Multimedia Stressor experience and who were
2) no training group (CG) Environment (MSE) in the experimental group
scenario showed greater relaxation
during the MSE scenario
Zbyszewski et al. (2013)88 120 soldiers Between subjects Two conditions: Physiological control After the training there was a
design 1) VR-based training group (EG); exposure to virtual stressor; correlation between anxiety
2) no training group (CG) Training was delivered in trait values and emotional
subgroups of 15 soldiers reactivity
Maciolek et al. (2013)43 118 soldiers Between subjects Two conditions: See Above After training, anxiety values
design 1) VR-based training group (EG); -Training was delivered in in EG group were
2) no training group (CG) subgroups of 15 soldiers significantly lower than in
the CG
Kosinska et al. (2013)39 4 soldiers Within subjects One condition: See Above Two participants achieved
design 10 SIT sessions -Training was delivered in better results in relaxation
subgroups of 4 soldiers during final exposition,
when compared to the
initial session
Ilnicki et al. (2012)36 118 soldiers Between subjects Two conditions: See Above Short-term effectiveness of
design 1) VR-based training group (EG); Training was delivered in the training as a method of
2) no training group (CG) subgroups of 15 soldiers tension reduction.
In the long-term results were
ambiguous
Winslow et al. (2015)87 40 novice Between subjects Two conditions: Five military-relevant training Utility of adding stressors
participants design 1) VR-based training group (EG); tasks under stress within external to the virtual
2) no training group (CG) Virtual Battlespace 2 (VBS2) training environments
Bouchard et al. (2011)11 1319 soldiers Within subjects A review and analysis of the Three sources were included Identification of several
design available literature and of data stressful situations that
collected post-deployment could be used in VEs
from respondents, recruited
within Canadian Forces

of physiological control exposure to a virtual stressor while anxiety values and emotional reactivity. These results can be
maintaining physiological control. taken into account when analyzing individual susceptibility to
In the first study, Zbyszewski et al.88 conducted a study SIT programs.
investigating the impact of personality, temperament, and stress In the second study, Maciolek et al.43 evaluated the influence
coping factors in a cyber-SIT program in soldiers preparing for of this type of cyber-SIT on the anxiety levels of ISAF soldiers.
their first deployment to Afghanistan (ISAF). There were 120 There were 118 soldiers who were selected randomly from the
soldiers that were split into two groups of 60 people each: the 1500-strong contingent that took part in the research. The sol-
Experimental (EG) and the Control (CG) Group. Soldiers from diers were split into two groups: the EG and the CG. Both
the EG, split into 4 subgroups of 15 each, took part in 10 SIT groups listened to a lecture on the nature of stress, its symp-
sessions. Both main groups filled out self-report questionnaires toms, and coping with stress. Soldiers from the EG were split
assessing coping skills, personality, and anxiety level. Results into four subgroups, each taking part in ten SIT sessions over
showed that before the SIT program, in the EG there was a neg- the next 5 d. At the same time, soldiers from the CG took part
ative correlation between values in anxiety and briskness, in the scheduled training in their military area. Results of self-
sensory threshold, and endurance; there was a positive correla- report questionnaires showed that, after training, anxiety values
tion between anxiety levels and emotional reactivity. After the in the EG were significantly lower than in the CG. In addition,
SIT program, in the EG there was a correlation between trait after deployment, both anxiety scores in the EG and the CG

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were significantly lower compared to values before training. stressors. Stressor selection was based on a few criteria, such as
Authors stated that, given the equivocal results of the experi- a frequency of occurrence of at least 50% among military per-
ment, further study and deeper analysis were necessary. sonnel who were involved in active combat and the feasibility of
In the third study, Kosinska et al.39 evaluated the effective- recreating the stressor in VR. After submitting stressors to these
ness of the same cyber-SIT program on four ISAF soldiers and criteria, eight stressful situations stood out (e.g., seeing dead
then assessed whether the soldiers’ temperament structure bodies or uncovering human remains and knowing that some-
was related to successful training. Soldiers took part in 10 SIT one has been seriously injured or killed).
sessions over 5 d. The initial and final arousal/relaxation in Another area of extreme interest to the military related
response to VR exposition was assessed using heart rate (HR) to the field of VR-based SMT programs is Resilience Training
indexes, while the temperament traits and structure were (RT), which aims to teach stress management techniques to sol-
assessed using a self-report questionnaire. The analysis of HR diers to increase their stress tolerance (Table II).
indexes showed that three soldiers succeeded in reducing their The first study conducted in this field was to test receptivity
arousal during the final session. Two of them achieved better to stress management techniques taught through virtual scenar-
results in relaxation during the final exposition when compared ios by military service members.75 There were 60 soldiers who
to the initial session. Three of the soldiers could effectively were randomly assigned and equally distributed to either an
reduce arousal after the exposition as an effect of the training. Experimental Group (EG) or a Control Group (CG). For three
Regarding the temperament structure, greater harmony was consecutive days, the EG looked at a video of a virtual island zone
found in soldiers who achieved weaker results in training. that contained an embedded script explaining how to practice
Finally, Ilnicki et al.36 investigated the effectiveness of a relaxation techniques (e.g., progressive muscle relaxation). Anal-
short collective cyber-SIT program conducted according to yses of surveys and a focus group suggested that EG participants
the same methodology developed by the VRMC. There were not only liked practicing relaxation techniques, but would also
118 soldiers from the 1500-strong Polish military contingent continue practicing these after the completion of the study.
in Afghanistan that were split into two groups: the EG and the In a second study, Bosse et al.10 investigated the impact of
CG. Results showed short-term effectiveness of the cyber-SIT virtual training on the subjects’ experienced stress responses.
program as a method of tension reduction. However, in the Driven by the goal to develop a virtual environment capable of
long term, results were ambiguous and authors suggested the training for mental readiness, the main research question was
need for further research. whether it is possible at all for such an environment to obtain a
In another recent study, Winslow et al.87 investigated how learned effect of successfully lowering subjects’ stress responses
stress induction through a virtual environment compares to in future situations. There were 10 healthy adults who partici-
and is influenced by the gold standard of socio-evaluative stress, pated in the experiment and were randomly assigned to either
the Trier Social Stress Test (TSST).38 There were 40 novice par- the EG or the CG. The CG participated in two rounds separated
ticipants divided into Experimental (EG) and Control Groups by a 6-h break. In these rounds participants were shown 150
(CG). Participants’ physiological and psychological stress lev- images from the IAPS picture set.40 After each image, partici-
els were assessed. After the collection of baseline measure- pants were asked to rate the emotional intensity of the picture.
ments, the EG was exposed to the TSST, while the CG was The EG also participated in these rounds. However, in between
not. Then, all the participants performed five military-relevant these two rounds, the EG participated in a virtual training ses-
training tasks under stress within Virtual Battlespace 2 (VBS2, sion. The virtual training used the same pictures as the other
Bohemia, Orlando, FL), a VE used for military training. Results rounds. But instead of rating them with a grade, the partici-
showed that virtual stressors alone may not be sufficient to pants were asked to view the pictures while actively reducing
induce a significant stress response (i.e., cortisol levels did not their emotional response until they felt comfortable looking at
increase significantly after the exposure to stressful virtual sce- the picture. The training resulted in significantly lower ratings
narios). Indeed, analysis indicates the utility of adding stressors of the images in the second test. In particular, the overall drop
external to virtual training environments. Interestingly, base- in emotional ratings of the training group was significant, while
line stress measurements were predictive of individual resil- the change in emotional ratings for the control group was not
ience to stress, including the impact stress had on physiological significant.
reactivity and performance under stress. The same authors replicated this study on a different sample
Only one study focused on the procedures followed to in a second experiment11 to investigate what type of VR-based
identify several stressful situations that could be used in VEs RT could be the most appropriate in order to obtain a successful
designed to train military personnel in stress management decrease of emotional responses toward negative stimuli. There
techniques.11 The aim was to list VEs that are significantly were 15 healthy adults who participated in the experiment and
stressful and specific enough to allow a reduction in the likeli- were randomly assigned to 1 of 3 groups: a first group perform-
hood of developing PTSD. A review and analysis of the avail- ing a session of virtual training in between these time points
able literature and of data collected post-deployment from (EG 1), a second group performing virtual training thereby
1319 respondents (recruited by the Canadian Forces) about applying reappraisal strategies (EG 2), and a group without any
the frequency of stressors and their association with psycho- training session (CG). In these rounds, 150 images from the
logical injuries were pulled together to propose potential virtual IAPS picture set36 were shown to the participants following the

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Table II. Information About the Selected Studies on VR-Based Resilience Training Programs.
VIRTUAL RESILIENCE
STUDY SAMPLE DESIGN CONDITION(S) TRAINING OUTCOMES
Stetz et al. (2009)75 60 soldiers Between subjects Two conditions: “Dream Island”, a virtual - Participants not only liked
design 1) VR-based training group (EG); environment that practicing relaxation techniques
2) no training group (CG) embedded script through VR scenarios but would
explaining how to practice also continue practicing these
Progressive Muscle after completion of the study
Relaxation and Controlled
Breathing
Bosse et al. (2012)10 10 healthy Between subjects Two conditions: Emotional pictures were - The VR-based training resulted
adults design 1) VR-based training group (EG); shown while participants in significantly lower ratings of
2) no training group (CG) were asked to actively the images supporting the
reducing the emotional hypothesis that reappraisal-
response until they felt based virtual training can be
comfortable looking at the used to reduce subjects’
picture emotional responses to
negative stimuli at later times
Bosse et al. (2013)9 15 healthy Between subjects Three conditions: Emotional pictures were - The VR-based training applying
adults design 1) VR-based training group 1 (EG1); shown while participants reappraisal strategies could be
2) VR-based training group 2 (EG2); were asked to actively the most appropriate in order
3) no training group (CG) reducing the emotional to obtain a successful decrease
response until they felt of emotional responses toward
comfortable looking at the negative stimuli with a
picture or to apply long-term effects of training
reappraisal strategies
Morie et al. (2011)52 27 healthy Within subjects One condition: A virtual jogging path, - The virtual jogging activity
adults design Virtual Biofeedback developed within Second tends to help participants feel
Life™, where control of the more relaxed and calm. While
avatar is done via rhythmic there was a decline in some
breathing positive emotions such as
inspired and enthusiastic, there
was a significant decline in the
negative emotions as well
Stetz et al. (2011)76 60 military Between subjects Two conditions: For three consecutive - The VR-based relaxation
medical design 1) VR-based training group (EG); mornings a virtual calming techniques were successful in
warriors 2) no training group (CG) environments was reducing overall anxiety levels
presented while practicing
relaxation techniques

same procedure of the previous study.9 Both EGs also partici- Stetz et al.76 conducted another study with the aim to test the
pated in these rounds, just like the CG. However, in between effectiveness of a VR-based RT based on progressive muscle
these two rounds, the EGs performed a virtual training session. relaxation (PMR) and controlled breathing (CB) techniques.
In addition to the above, the participants in all three groups There were 60 military medical warriors who participated in the
participated in a second part of the experiment that afternoon study and were divided in 2 groups: the EG and the CG. For three
and then 6 mo after the first part. Results showed that the EG 1 consecutive mornings, participants in the EG were presented
resulted in a significant increase of emotional ratings for nega- with virtual calming and relaxing environments while prac-
tive images, while EG 2 significantly decreased emotional rat- ticing PMR and CB techniques. The participants also engaged
ings for those images. in two stressful hands-on tasks (simulations of surgery). Results
Morie et al.52 conducted a preliminary study that measured on self-report questionnaires showed that participants in the EG
mood and arousal effects produced by engaging in a biofeed- were less anxious post-immersive relaxation training as com-
back (virtual jogging) scenario where control of the avatar is pared to the CG. In addition, even if the VR-assisted relaxation
achieved via steady, rhythmic breathing. There were 27 partici- techniques were unable to be evaluated during stressful situa-
pants, not specifically selected from the veteran population, tions (i.e., the stressful tasks failed to increase participants’ anxi-
who used a male avatar wearing Army fatigues and were tested ety levels), they were successful in reducing overall anxiety scores.
at the same virtual location within Second Life. Results on self-
report questionnaires showed that participants’ experiences
using the jogging path had effects on these measures, resulting DISCUSSION
in a significant decline in mean scores for all three scales. Over-
all, results indicate that the virtual jogging activity, in its totality, SMT programs are increasingly being adopted in the mili-
tended to help participants feel more relaxed and calm. tary field for soldiers’ and aircrew professionals’ resilience

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empowerment and primary stress prevention.16,74 Stress can simulations developed for VRET63,68 to create a series of immer-
worsen performance, affecting individuals’ cognitive and emo- sive virtual interactive narrative episodes that present examples
tional processes. Thus, knowing how to manage stress is a of the types of emotional challenges soldiers may face during
fundamental skill for military personnel that can have an deployment. It has developed and disseminated training that
impact on job performance, as well as on emotional and physi- aims to improve the emotional coping skills and resilience of
cal health.12,37,54 In recent years, advanced technologies includ- soldiers.67 Although VRAS and STRIVE are both complex and
ing virtual reality have been included in SMT in order to innovative programs that may provide important new ele-
develop more innovative and effective training.29,65 Here, we ments to SMT programs for military personnel, the lack of
focused specifically on SMT programs for military personnel experimental studies significantly limits their impact. As VR
that integrated virtual reality in order to describe this emerging and, more generally, the adoption of advanced technologies
and promising approach to improving resilience to stress. (e.g., augmented reality, serious games) play a greater role in
The main observation to be drawn from this review is that the future SMT military field,58 it will become crucial that
VR-based SMT programs (both developed on SIT and RT pro- future studies be methodologically and numerically stronger
grams) can reduce subjects’ emotional responses to negative to enhance the adoption of these technologies.
stimuli,35,39 even at later times.9,10 This type of training, there- The second challenge, closely related to the first, is that the
fore, can help military personnel handle emotional and physi- experimental studies conducted to date have used few and
ological responses to stressors in order to maintain performance heterogeneous measures to assess the effectiveness of the VR-
even in situations of high stress. based SMT programs that have been developed. Several studies
Interestingly, VR also appears to be a promising tool to included in this systematic review (e.g., Bosse et al.9,10) do not
assess individuals’ resilience to stress and to identify the impact include specific measures of individuals’ stress levels before
that stress can have on physiological reactivity and perfor- and after the VR-based training, making it very difficult to
mance.87 Virtual stressful scenarios can be used to assess the understand differences before and after SMT. In the future it
physiological response to stressors and correlate that response will be important to define a set of standard measures for the
to task performance, making it possible to train practitioners to evaluation of the training. These measures should include:
identify resilient individuals or those at risk for stress-related 1) individuals’ subjective stress levels (e.g., self-report ques-
performance issues. tionnaires); 2) individuals’ objective stress indexes (e.g., cortisol
The third important observation that emerges from this and HRV data); and 3) individuals’ experience of the VR sys-
review is that VR can also be used to provide interactive SMT tem (e.g., self-report, interviews, and observational data).
programs useful for decreasing levels of perceived stress and The third main challenge is that studies conducted to date
negative affect in military personnel.9,52,76 In particular, the have included only very small numbers of subjects, in some
review showed that virtual environments combined with cases even recruited among military personnel.52
arousal reduction strategies (e.g., systematic desensitization A fourth and final fundamental challenge is the lack of stan-
through exposure to stressful scenarios, traditional relaxation, dardized procedures used in the definition of SMT protocols
and biofeedback techniques) effectively increase military resil- based on the use of VR. This challenge regards all the ideation
ience to stress. and development phases of this type of training. The following
According to the results of this systematic review, SMT should be included: 1) the definition of the specific objectives of
programs based on VR applications appear to be a promising the training on the basis of the sample concerned; 2) definition
approach; there are even studies that have effectively combined of VR scenarios both for the gradual exposure to stressors and
traditional SMT protocol with VR technology. However, there for the training of coping skills and resilience; and 3) the test of
are some methodological challenges. the effectiveness of the VR-based SMT program through the
The first challenge is the number of studies carried out in execution of clinical trials. To define a series of “best practices”
this research field. Because it is an emerging field of research, to be used in the development process of VR-based SMT could
there are still relatively few studies in the literature that meet the increase the ultimate effectiveness of any program developed.
requirement of using VR in SMT programs. Most of the studies,
in fact, have VR-based SMT programs only in theory, without ACKNOWLEDGMENTS
providing data about trials conducted to test the effectiveness of
the proposed approaches. In particular, we could not include in Authors and affiliations: Federica Pallavicini, Ph.D., M.D., Luca Argenton,
the review important programs developed in recent years for Ph.D., M.D., and Fabrizia Mantovani, Ph.D., M.D., Department of Human Sci-
SMT that integrate VR as a “virtual reality adaptive stimulation” ences for Education “Riccardo Massa”, Centre for Studies in Communication
Sciences CESCOM, University of Milano-Bicocca, Milan, Italy; and Luciana
(VRAS) or “Stress Resilience in Virtual Environments” (STRIVE). Aceti, M.D., and Nicola Toniazzi, M.D., Leonardo-Finmeccanica Airborne &
VRAS is a predeployment mental stress resistance training Space Division, Rome, Italy.
based on the use of virtual reality that was developed for the
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