Reliving the war - as therapy

Hal Bernton
The Seattle Times

The nameplate on the door reads "Virtual Reality Iraq."

Inside, you sit in a chair perched upon a vibrating platform, don a headset and embark on a stark video journey through a desert war zone rife with snipers and roadside bombs.

Sometime this summer, the first patients at Fort Lewis will venture into this mock combat zone where they can see, hear and - with a scent machine producing odors of diesel fuel, sweat, gunpowder and garbage - even smell the war in Iraq.

Madigan Army Medical Center doctors hope that the use of virtual-reality therapy can ease - or curb - the symptoms of post-traumatic stress disorder (PTSD), which afflicts expanding numbers of U.S. soldiers who have returned from war.

With the aid of a therapist, the patients gradually will intensify the virtual-reality experiences in sessions that may stretch out for several months. The goal is to help troubled soldiers gain control of the physical and emotional responses triggered by combat memories.

"It gives them the cues, the reminders and the stimulus without the life-threatening experience," said Capt Greg Reger, the Fort Lewis psychologist who will launch the therapy at Madigan. "Over time, it should really help extinguish those traumatic responses."

Post-traumatic stress disorder is a severe reaction to war that includes a kind of hyper-alertness, nightmares and depression. It may be triggered by any number of combat reminders such as fireworks, television scenes of the fighting or a crowded highway that awakens a soldier's memories of Iraqi convoys.

A 2004 study published in the New England Journal of Medicine predicts 15 to 17 percent of Iraq war veterans could develop PTSD. Other studies suggest that 25 percent or more of combat veterans will eventually suffer from that illness or other mental-health problems.

In 2005, the Pentagon's Office of Naval Research provided $4 million for research in California and Hawaii and at the University of Washington to evaluate the use of virtual-reality treatment. The Army Telemedicine and Advanced Technology Research Center is spending more than $200,000 on the Fort Lewis program.

So far, only a handful of combat veterans nationwide have undergone virtual-reality therapy. Though results are encouraging, it is still too early to determine its effectiveness.

Critics caution that there is no high-tech fix for the emotional trauma of modern combat, which may include debilitating guilt over the death of fellow soldiers or the killing of others.

"My prediction - and of course I've been wrong before - is that virtual reality may have limited benefits for some people but is not going to be a widely prescribed treatment," said Dr. Murray Raskind, a VA Puget Sound Health Care System psychiatrist, who has gained national recognition for his research into drug therapy for post-traumatic stress disorder.

Proponents believe virtual-reality treatment is a tool that can be used along with counseling and drug treatment to help patients.

The virtual-reality program builds on "exposure therapy," which involves a patient reliving - and hopefully coming to terms with - traumatic experiences through talking sessions with therapists. In the past decade, this type of treatment has helped many phobia patients gradually overcome their fears of spiders, dogs or flying.

Some survivors of the Sept. 11 attacks in New York have also been helped by exposure to a recreation of the collapse of the World Trade Center towers.

In a pilot study, five of eight survivors showed such significant improvements that they no longer were diagnosed with PTSD, according to a study published in 2006 by the New York Academy of Sciences.

"People who had failed to respond with traditional therapy, responded to this," said Hunter Hoffman, a University of Washington researcher who was one of the study's co-authors. "Virtual reality helps people to become emotionally engaged so they can access their memories. Avoidance is a big issue."

Over the past year, eight Iraq combat veterans have undergone treatment at Emory University in Atlanta and the Naval Medical Center in San Diego. Of those patients, five showed enough improvement that they no longer were diagnosed with PTSD. Another showed no improvement and two dropped out of the treatment.

"We're encouraged as hell and fighting like hell to get it into different places," said Dr. Albert Rizzo, a University of Southern California psychologist who helped develop the Iraq virtual-reality systems used on these patients.

Fort Lewis patients will also use a virtual-reality system developed by Rizzo and his colleagues. They will receive that therapy as part of a broader treatment plan that includes counseling and possibly drugs.

They will be under the care of Reger, who spent a year in Iraq, where he used more traditional exposure therapy to help soldiers overcome some fears. One soldier, for example, developed an intense fear of heights. To overcome the phobia, Reger, in counseling sessions, gradually helped the patient ascend a tall structure at the base.

Reger took the virtual-reality computers, headsets and other equipment to Iraq but wasn't ready to use them on patients. He found the equipment was sturdy enough to withstand the heat, dust and other rigors of deployment.

Since his return to Fort Lewis, Reger has been working with Rizzo to improve the realism of the video system in preparation for this summer's launch of treatment efforts.

The Fort Lewis system offers two different scenarios: a desert ride in a Humvee and a treacherous foot patrol through an Iraqi city.

The sounds, scents and shaking effects are intended to try to engage the patients. The videos have been scrutinized by Fort Lewis soldiers, who have suggested improvements, such as putting many more people on the streets in the urban scenario. This system is a souped-up version of the Army's "Full Spectrum Warrior," which is used as a training tool for troops. It can be built for less than $10,000, according to Rizzo.

Some therapists caution that virtual-reality videos can be too realistic and overstimulate the patients.

Reger says that he will ease Fort Lewis patients into the most intense scenarios over a period of weeks. The sights, sounds and scents will be ramped up as the patient gets more comfortable with the experience. In the early sessions, the patient might only ride in a virtual Humvee on a quiet road, and if their discomfort remains high, then they won't move to a more intense level. During the sessions, Reger will also offer counseling.

Eventually, Reger wants to add monitoring to track the physiological reactions of the patient to the virtual-reality experience.

Other clinicians will eventually be trained to use the therapy as part of a new "virtual-reality center" planned for Madigan.

Meanwhile, the University of Washington's Hoffman is working with researchers in Hawaii to develop an urban-warfare scenario that can help treat patients at Tripler Army Medical Center in Hawaii.

Eventually, virtual reality might be used in the combat zone. A soldier traumatized by a bomb attack on a convoy could be put through a simulated road trip. A therapist then would gauge the response and advise the commander on whether the soldier is ready to return to duty.

"We can talk through it, we can have him imagine it - we can then proceed to have him drive around ... in a safe environment," Reger said. "But at some point the ability to present simulated combat-convoy experience can be extremely valuable."