A group of clinicians who began treating post-traumatic stress disorder (PTSD) with virtual reality are now developing a system that could better prepare combat medics for battle. Using augmented reality, the Virtual Reality Medical Institute hopes to be able to harden troop's physical and emotional response to the stress of combat. The end result would be soldiers who are better prepared to endure the combat environment, and are more effective at saving the lives of their comrades while under fire.
The Virtual Reality Medical Institute began life nearly 20 years ago. Its first few experimental methodologies used VR therapy to treat patients with a fear of flying. Using VR goggles, realistic airline seats and a surround-sound speaker system, they were able to gradually expose patients to simulated air travel and ultimately help them fly commercially.
"We operated a few clinics around the country," says Dr. Mark Wiederhold. "Most of our ideas came from treating our patients, and so in that sense from the beginning we’ve really been able to understand what works and what doesn’t work right in the beginning.
"Most of our success is because our patients tell us what works," he added. "It's amazing to me how a lot of people want to share, despite the fact they've had difficulties or some issues with their healthcare in the past. They've been very open and very helpful so that we're able to take the lessons learned from our clinics and help more people and develop better technologies. It’s given us a level of insight that has been very valuable."
For those patients who were able to adapt to the VR environment, the outcomes were surprisingly effective.
"We had an 84-year-old lady with a fear of flying," Wiederhold said. "She was able to fly. After 10 years of fear, she was able to see her grandchildren. She’d never actually seen them before."
After these early successes, Wiederhold says they then began to adapt the treatment to work with soldiers returning home from war in Iraq and Afghanistan. VRMI built a virtual Fallujah, designed convoy simulations and other environments, and then placed soldiers inside an immersive VR environment while monitoring their physiological response. Stimuli like roadside bombs and ambushes were slowly introduced, and soldiers were trained on how to moderate their physical and emotional response.
Over time, past traumas were eased out of soldiers’ minds like splinters. VR was used in these clinical settings like a drug, and it’s dosage was carefully monitored.
"We're able to determine their level of arousal, their anxiety, and that's very important for driving the session and in terms of what type of goals you want to reach for that day."
The system could easily be mistaken for a video game if not for the blocky, low resolution graphics. But this, Wiederhold says, is a necessary concession to PTSD patients’ needs.
"It's not a game," Wiederhold says. "It's not meant to be a game. It's a therapeutic tool, and I can tell you that we could take somebody with post-traumatic stress and sometimes we have to begin by letting them walk down an empty street in an empty town in Iraq with nothing going on, and that is sufficiently overwhelming for them."
Placing them into a modern video game would be too stressful, too specific. Furthermore, Wiederhold said, it’s important for patients to be able to overlay their own experiences into the VR setting, and overly specific images could work against that process.
That’s part of why VR therapy doesn’t work for everyone, Wiederhold said.
"The people that respond well are the people that can get immersed and present," Wiederhold said. "Those that can have subjective and objective arousal.
"It's not a game. It's not meant to be a game."
"It’s something … called synchrony. Basically, when you have an alignment of your subjective and objective response. When you feel scared, your heart rate's up. So it's both subjective, ‘I feel scared,’ and objective, measurable, ‘My heart rate's up.’"
The success of the institute’s VR treatment regimen has led the U.S. military to stage their services in active combat zones. Troops can literally go out on a mission, endure a real-life trauma, and days or weeks later go into VR therapy sessions designed to temper their response to those memories. The goal is to normalize the therapy, so that it can become part of the broader spectrum of treatments available to troops without developing a negative stigma.
This type of exposure has allowed Wiederhold and his colleagues to introduce the same clinical techniques for something that the military calls "stress inoculation training," or SIT. But instead of low resolution, game-like experiences the goal is to create a hyper-realistic setting that blends live actors and augmented reality.
From VRMI’s website:
"Deployed personnel must often perform in extremely stressful environments, and optimum performance under such conditions requires the management of physiological, psychological, and emotional responses to stressful stimuli. SIT is a technique to help "inoculate" individuals to future potentially traumatizing stressors. An acute stress reaction (ASR) or combat and operational stress reaction (COSR) can occur during exposure to exceptionally stressful events, resulting in extreme sympathetic nervous system arousal and impaired performance."
VRMI has experience using trained actors and Hollywood special effects to place combat medics into simulated combat environments, as shown in the video below.
Warning: This video contains realistic depictions of combat injuries.
In their design laboratory they’re currently working on ways to blend simulated medical interventions with AR systems, like Google Glass or something similar, to enhance the immersive quality of the activity.
Essentially, VRMI is seeking to use a kind of VR to train soldiers and keep them from freezing up in stressful situations. Wiederhold and his colleagues have shown that the lessons they’ve learned from using VR treatment for PTSD can be applied proactively to soldiers before they enter combat, effectively making them immune to combat stress in the same way that a flu shot can keep you from getting sick.
SIT training also has the added benefit of reducing the incidence of PTSD. Again, from VRMI's website: "Repeated exposure enables performers to gradually become desensitized to stimuli that may initially elicit such strong physiologic arousal that performance is impeded (i.e., 'freezing in the line of fire') and psychological trauma is more likely."
The ability to, in a clinical setting, adjust someone’s response to certain stimuli comes with ethical responsibilities, Wiederhold said. Because of the type of work that they do, VRMI is contacted by many reality TV shows.
An example of augmented reality being used by VRMI for rehabilitation training.
"They want us to do outrageous things," Wiederhold said. "I had a phone call from this one guy who wanted to put people through rotating drums that were on fire, and I was like, ‘Hmmm.’ We’re between two worlds. On the one hand, we have to be responsible. … There’s unethical stuff we can’t do."
For these reasons, Wiederhold said that VRMI has worked with the American Psychological Association and the National Institutes of Health to create a nonprofit that certifies therapists to perform virtual reality therapy.
VRMI's flight medic suite.
But in the end, when it comes to preparing soldiers to go into combat, Wiederhold said the obligation to protect warfighters comes first.
"If you're going to send people into a battle," he said, "you have a responsibility to prepare them and give them the best training that we possibly can."