‘It’s Going To Be Kind Of Loud’: Using Virtual Reality to Treat Post-Traumatic Stress Disorder (PTSD)

For most of us, virtual reality is synonymous with video gaming entertainment. In October 2016, Sony released its highly anticipated PlayStation VR. The $550 price tag for the headset alone proved of little deterrence to hard-core gamers - the first Australian shipment was completely sold out before it even hit the shelves.

However, while recreation may be the chief domain of virtual reality's early days, this cutting-edge technology is also gaining traction in the medical field. Researchers are finding some of its best applications in psychotherapy, where it is being used to effectively treat a number of conditions, such as post-traumatic stress disorder (PTSD).

Virtual reality comprises a set of computer technologies which combine to provide an interface to an interactive, computer-generated world. Along with software, virtual reality uses a range of input hardware to track the user’s actions (such as motion trackers and data gloves), as well as output media devices (including head-mounted displays and rumble pads) which integrate them into their virtual environment. This creates an immersive, multi-sensory experience and transports the user to another reality where they can navigate and interact with their surroundings in real time. Ultimately, it invokes a sense of true presence in an artificial environment.

Doctor Patrick McGrath works with returned war veterans suffering from PTSD at Alexian Brothers Behavioural Health Hospital in Illinois, USA. He explains that when a veteran seeks his assistance, it is often because their flashbacks and nightmares are so intense that they are interfering with their day to day lives. For patients with PTSD, even basic tasks like grocery shopping or driving can create stressful situations and lead to triggers and extreme paranoia. For example, a person walking along a footpath wearing baggy clothes might be perceived as a terrorist concealing explosives and transport the patient right back to their traumatic experience as though it were happening again.  

Using virtual reality, Dr. McGrath subjects his patients to a simulation of their trigger or traumatic memory and helps them face it without clinging to their usual coping strategies of avoidance, distraction and seeking reassurance. This is a form of exposure therapy referred to as in-virtuo (virtual reality). The two other approaches of exposure therapy in psychology are in-vivo (‘in the living’) and imaginal (visualisation).

In-vivo exposure involves the patient confronting their phobic situation in the real world. While this can be highly successful in certain cases, its numerous drawbacks render it a nonviable option for most. These include the cost, time and inconvenience associated with leaving the therapist’s office to experience the real life phobia; not to mention the lack of patient confidentiality. Furthermore, those with severe conditions are rarely willing to subject themselves to the intensity of the exposure in the first place and can risk re-traumatisation if they do.

At the other end of the spectrum, imaginal exposure involves the patient using mental imagery to visualise their phobic situation, inside the comfort and safety of the therapist’s office. However, many patients struggle to effectively conjure the phobic situations in their minds and the necessary levels of realism cannot be reached. So while this gentler approach is currently the most widely-used type of exposure therapy, it tends to be a more protracted process and yields fewer substantive results.

In-virtuo exposure is still in its early phases, but results so far have presented it as an exciting solution to the limitations of both in-vivo and imaginal psychotherapy. It provides stimuli to engage patients who experience difficulty imagining scenes while on the other hand, providing a less harrowing experience for those too phobic to confront real-life situations. Moreover, virtual reality has the ability to generate stimuli of a much greater magnitude than in-vivo. The therapist can flexibly adapt the virtual environment to facilitate the controlled and gradual progression of treatment in line with the patient’s needs.

‘Brandon’ is one of Dr. McGrath’s PTSD patients who agreed to have one of his in-virtuo treatment sessions filmed for academic purposes. He was hit by an IED explosion while driving a Humvee in the Iraq War in 2013. Nobody was killed, but his front seat passenger sustained a serious arm injury and Brandon was left heavily affected by the ordeal.

The video begins with him entering Dr. McGrath’s office and taking a seat. He is in his mid-thirties and wearing a loosely fitting, pale blue button-down shirt tucked into beige slacks. His brown hair is combed neatly to the side and he wears round spectacles. The timid nature of his movements gives him the appearance of being smaller than he is, almost as though he is trying to take up as little space as possible so as to not impose on his environment.

Dr McGrath asks him how he has gone since their last session. “Alright, I guess,” replies Brandon with a pained smile. “It’s tough to get used to.” He reveals that he managed to drive himself to today’s session, the first time he has done so. Dr McGrath enquires how that went. “I got some of the same feelings that I told you about, but I was able to deal with it. I was probably about halfway here and I started actually to feel a little bit better. Some of the same stuff was coming up. My heart would start to beat really, really quickly. I'd get lightheaded.” He speaks with an apologetic tone, his eyes downcast.

Dr McGrath explains that for today’s in-virtuo exposure therapy, Brandon will be driving in the Humvee again, dealing with explosion noises, and if he’s ready, the IED explosion. Brandon nods, resigned to the dread of once again having to confront the trauma that brought him here. The doctor fits him with the head-mounted display before passing him the hand controller for steering. He then turns on the volume and the rumble pad below Brandon’s feet, pausing to explain that the olfaction (‘smell’) box will not be used until a later session due to its severely triggering effects.

Image: 807th Medical Command (Deployment Support) under Creative Commons

Once he is all ‘plugged in’, Brandon is asked to drive around for a while to help him acclimatise to the virtual world: in his case, the desolate middle eastern desert. Dr McGrath sits at his computer screen, where he is able to watch and control the virtual environment. He switches the conditions to dusk to accurately emulate the memory.

After being told to look over at his passenger, Brandon explains that he is feeling anxious from the anticipation of what is going to happen. Dr McGrath reassures him that there will be no surprise exposures and allows Brandon to simply drive around for a little while until he feels comfortable enough to proceed.

The next element to enter the simulation is helicopters. Then, in order to build up to the IED work, Dr McGrath explains that he will set off a few low-level explosions. Brandon breathes heavily and describes tingling in his hands. The doctor says he will continue to do a few more explosions at regular intervals until Brandon feels less anxious.

At this point, Dr McGrath states that he is going to introduce a sound to Brandon before adding its visual component. He asks him to stop driving for a moment to focus on the sound, and then describe what it elicits.

“Here we go, it’s going to be kind of loud...”

The explosion makes Brandon inhale sharply and he jolts his head back, his body tense.

“That takes me right back to it,” he says. “I'm feeling scared and I've got that same thought going through my head like I've got to get out of here. It's a little easier to deal with now. My heart's going a mile a minute, my hands are sweating.” He lifts his hand to his chest before quickly returning it to his lap and rubbing his thigh anxiously. He smiles in embarrassment and is visibly shaken.   

Dr McGrath explains to Brandon that he will now be adding the full visual but stresses that no one will be injured. Brandon’s breathing quickens once more and he states that his anxiety level has reached a seven on the scale of one to ten. When it eventually drops back down, Dr McGrath tells him it is time to experience the culmination of all elements to recreate everything that happened in the true event. The passenger will be injured this time, and Brandon is instructed to watch it unfold and confront the memory: ‘to sit with it’.

The explosion goes off. The passenger clutches an open wound in his shoulder, yelling and writhing in pain. Brandon watches in silence, the colour rising in his cheeks. He sits very still.

“Describe for me right now what’s going through your mind.”

“First, he’s hurt and I’ve got to get us out of here. It’s my responsibility.”

“And is that what happened?”

“Yeah, I was able to get us back.”

“So Brandon, let me ask you this. How much do you focus on the fact that you were able to get you and everybody else out of there versus how much do you focus on that experience right there?”

 “I'm always still here.”

“If we can get you to not have that response to this anymore, you won't be stuck here anymore.”

“That'd be great.”

Dr McGrath repeats the same simulation a few more times to have Brandon learn how to handle it until his anxiety level reduces. When it finally returns to a four, the doctor declares today’s session over and Brandon leaves looking emotionally drained.

To conclude the video session, Dr. McGrath explains to his audience that over time, they hope to see the virtual reality treatment program show a decrease in the patient’s anxiety even as they encounter increasingly difficult memories. “Ultimately, we build up to the highest level session and I will put it on random. And bombs will go off and there's smoke and there's just chaos and helicopters are flying. And when I've done that with people, that last session, after 20 minutes they take off the headset and they say, I'm good. It's time to go home now.”

In addition to PTSD, virtual reality is currently being successfully used to treat numerous phobias, such as arachnophobia and fear of heights, as well as social anxieties. It’s also making waves with its pain control capabilities. Studies have revealed that brain scans taken of burns patients immersed in a customised virtual environment called ‘SnowWorld’ during wound care have shown a significant reduction in their reception of incoming pain signals. Some have even described this ‘distraction therapy’ to be a more effective pain relief than morphine. While virtual reality is still emerging in the field of psychotherapy, early studies around the globe are producing very promising results. As technology continues to improve, there will undoubtedly be even more exciting breakthroughs and applications for virtual reality in the medical field.

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Jaime Boyanich is studying Professional Communications at RMIT University. She grew up in the Perth Hills before moving to Melbourne, and in her spare time enjoys running, reading and watching reality trash TV. She doesn’t know if any of that is useful information.

SOURCES

SAGE Video: Treating PTSD with Virtual Reality
The Conversation: 10 Cool Applications for Virtual Reality That Aren’t Just Games
Carbon Culture Review: Virtual Reality and Psychotherapy
Springer: Advances in Virtual Reality and Anxiety Disorders

Header image: Knight Center for Journalism under Creative Commons