The Humvee engine rumbles as you drive through a stretch of desert in Iraq, past the occasional cluster of low buildings along a street strewn with trash.
Suddenly, the vehicle in front of you explodes and the sky begins to fill with smoke. Just beyond the wreck, you see the silhouette of an insurgent shooting to kill any survivors or rescuers. As the scene plays out on tiny screens mounted to the goggles you wear, the radio chatter playing in your headphones erupts in panic, and the smell of diesel fuel wafts over you.
For someone who has never lived it, experiencing this scene from the Iraq War via virtual reality is unnerving. For those who have, it just might be healing.
Increasingly, therapists are using virtual reality systems in conjunction with a form of talk therapy to treat veterans with symptoms of post-traumatic stress disorder, tailoring the scenes to patients’ memories to help them relive and process difficult emotions.
As many as one in five people who served in Afghanistan or Iraq suffer from symptoms of PTSD, though estimates are higher for certain groups of veterans. Few seek treatment.
Researchers developing the virtual reality system, which so far has been distributed to about 70 clinics and hospitals around the country, say it may offer a familiar way into therapy for a generation of service members who grew up playing video games, or an effective treatment for those not helped by other kinds of care.
A primary means of treating PTSD today is “prolonged exposure therapy,” during which a clinician, through conversation, helps the patient to repeatedly recall traumatic events and process the emotions that come up. Small studies have shown that adding virtual reality to that therapy can help, and researchers are working to determine just how effective it can be and which veterans could benefit most.
The technology may help some patients remember aspects of their experience that they avoid thinking about even during talk therapy, said Peg Harvey, a psychologist with the Home Base Program, a Boston clinic for veterans and their families run by the Red Sox Foundation and Massachusetts General Hospital.
The clinic began using the virtual Iraq/Afghanistan program this spring with a small number of patients. The system was developed in partnership with the firm Virtually Better and the University of Southern California Institute for Creative Technologies, with funding from the Office of Naval Research.
Patients can navigate by Humvee or on foot while a therapist tailors the scene to experiences they have previously recounted: A car bomb explodes alongside a busy market, momentarily blocking out the call to prayer playing from a nearby mosque, and when the smoke clears there are bodies in the street. Or, a Humvee comes under attack from insurgents who shoot down at the vehicle from their position on a roadway overpass.
The patient sits in a seat that vibrates like the engine of a Humvee or with the force of an explosion, the game controller can be swapped for a model M16 rifle, and a black box nearby sends out smells, on command, from small vials with labels such as “Moroccan market” or “body odor.”
Patients often remember only fragments of traumatic events. That can lead to “messy interpretations” or guilt about whether they did enough to help someone who was hurt or killed, Harvey said. One goal of prolonged exposure therapy is to put the pieces back together.
“There’s often kind of a process of looking at the reality, pulling that context back that gets so easily lost, and helping the person see that most likely they did the best that they could,” she said.
Virtual reality might help some patients more easily gain that context, said Barbara Rothbaum, director of the Trauma and Anxiety Recovery Program at Emory University School of Medicine who started using virtual reality to treat people with a fear of heights in the 1990s and later created a virtual Vietnam.
A common symptom of PTSD is emotional avoidance — or being unwilling to think about a traumatic event or unable to feel the emotions related to it. Soldiers are taught to put their feelings aside in order to continue their job. But, later, they need to be able to face those emotions.
“With the virtual reality, it’s harder to avoid,” Rothbaum said.
Army Sergeant William Chagnon, a field medic who lived on a Baghdad base that was regularly attacked in 2007 and 2008, began treatment at the Home Base Program in May and soon after tried virtual reality. He has taken a break from therapy but plans to return next month and believes it has helped him.
The 42-year-old from Saugus said he hadn’t made progress in dealing with his anxiety or processing troubling memories through talk therapy alone. He likened it to struggling to remember the words to a song.
With virtual reality exposure therapy — seeing the desert sky, hearing familiar sounds, and even feeling the rumble of a blast in his seat — it is as if “the song comes on and, all of a sudden, you remember every single measure,” he said. “It all comes right back up.”
Several studies underway are aimed at sorting out who might benefit most from virtual reality exposure therapy and how to improve it. Rothbaum is looking at the effectiveness of using virtual reality exposure therapy with different medications.
The National Center for Telehealth and Technology at Joint Base Lewis-McChord in Washington is enrolling several hundred soldiers there and at Fort Bragg in North Carolina in a controlled study to compare traditional prolonged exposure therapy to treatment with virtual reality. Psychologist and investigator Greg Reger said the study will allow his group to look at patient characteristics to see, for example, whether a soldier’s age affects how responsive they are to the technology or whether people with certain kinds of traumatic experiences see greater gains than others.
The growing interest in virtual reality therapy reflects a “quantum change” happening in military thinking, said Albert “Skip” Rizzo, associate director of the Institute for Creative Technologies, which is now developing a more advanced system depicting the two wars. There is a shift away from the idea that a person who gets treatment is weak and toward the realization that treatment is a means for service members to keep their minds — not just their bodies — fit, Rizzo said.
The Veterans Affairs health system in Boston had a virtual reality system but stopped using it about a decade ago because patients were unwilling to try the newfangled system. But Terence Keane, who directs a division of the National Center for PTSD in Boston focused on behavioral science, said the newer system is more advanced.
Keane said he is encouraged by how virtual reality has made more therapists interested in prolonged exposure therapy, considered by many people to be the gold standard in PTSD care though still not widely available to patients. But, he said, unless the virtual reality exposure therapy proves to be more effective for some patients than the talk therapy alone, it may not be worth the cost.
The cost of a standard Virtually Better system can range from about $30,000 to $40,000 depending on which of the added tools the providers want and how much training they need. The next step, Keane said, is to make it cheaper and available to many more clinicians and their patients.