Greg M. Reger

Effectiveness of Virtual Reality Exposure Therapy for Active Duty Soldiers in a Military Mental Health Clinic

Exposure therapy is an evidence-based treatment for posttraumatic stress disorder (PTSD), but research evaluating its effectiveness with active duty service members is limited. This report examines the effectiveness of virtual reality exposure therapy (VRE) for active duty soldiers (N = 24) seeking treatment following a deployment to Iraq or Afghanistan. Relative to their pretreatment self-reported symptoms on the PTSD Checklist, Military Version (M = 60.92; SD = 11.03), patients reported a significant reduction at posttreatment (M = 47.08; SD = 12.70; p < .001). Sixty-two percent of patients (n = 15) reported a reliable change of 11 points or more. This study supports the effectiveness of exposure therapy for active duty soldiers and extends previous research on VRE to this population.

Virtual Reality Exposure Therapy for Active Duty Soldiers

Virtual reality exposure (VRE) therapy is a promising treatment for a variety of anxiety disorders and has recently been extended to the treatment of posttraumatic stress disorder (PTSD). In this article, the authors briefly review the rationale for VRE and its key processes. They illustrate the treatment with an active-duty Army soldier diagnosed with combat-related PTSD. Six sessions of VRE were provided using an immersive simulation of a military convoy in Iraq. Self-reported PTSD symptoms and psychological distress were reduced at posttreatment relative to pretreatment reports, as assessed by the PTSD Checklist-Military Version and the Behavior and Symptom Identification Scale-24. The case outcomes parallel those reported in the research with other disorders and suggest the applicability of VRE in treating active duty soldiers with combat-related PTSD.

Development and early evaluation of the Virtual Iraq/Afghanistan exposure therapy system for combat-related PTSD.

Numerous reports indicate that the growing incidence of posttraumatic stress disorder (PTSD) in returning Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) military personnel is creating a significant health care and economic challenge. These findings have served to motivate research on how to better develop and disseminate evidence‐based treatments for PTSD. Virtual reality‐delivered exposure therapy for PTSD has been previously used with reports of positive outcomes. The current paper will detail the development and early results from use of the Virtual Iraq/Afghanistan exposure therapy system. The system consists of a series of customizable virtual scenarios designed to represent relevant Middle Eastern contexts for exposure therapy, including a city and desert road convoy environment. The process for gathering user‐centered design feedback from returning OEF/OIF military personnel and from a system deployed in Iraq (as was needed to iteratively evolve the system) will be discussed, along with a brief summary of results from an open clinical trial using Virtual Iraq with 20 treatment completers, which indicated that 16 no longer met PTSD checklist‐military criteria for PTSD after treatment.

Virtual Reality Goes to War: A Brief Review of the Future of Military Behavioral Healthcare

Numerous reports indicate that the incidence of posttraumatic stress disorder (PTSD) in returning OEF/OIF military personnel is creating a significant healthcare challenge. These findings have served to motivate research on how to better develop and disseminate evidence-based treatments for PTSD. Virtual Reality delivered exposure therapy for PTSD has been previously used with reports of positive outcomes. This article details how virtual reality applications are being designed and implemented across various points in the military deployment cycle to prevent, identify and treat combat-related PTSD in OIF/OEF Service Members and Veterans. The summarized projects in these areas have been developed at the University of Southern California Institute for Creative Technologies, a U.S. Army University Affiliated Research Center, and this paper will detail efforts to use virtual reality to deliver exposure therapy, assess PTSD and cognitive function and provide stress resilience training prior to deployment.

An Intelligent Virtual Human System For Providing Healthcare Information And Support

Abstract Over the last 15 years, a virtual revolution has taken place in the use of Virtual Reality simulation technology for clinical purposes. Shifts in the social and scientific landscape have now set the stage for the next major movement in Clinical Virtual Reality with the “birth” of intelligent virtual humans. Seminal research and development has appeared in the creation of highly interactive, artificially intelligent and natural language capable virtual human agents that can engage real human users in a credible fashion. No longer at the level of a prop to add context or minimal faux interaction in a virtual world, virtual humans can be designed to perceive and act in a 3D virtual world, engage in spoken dialogs with real users and can be capable of exhibiting human-like emotional reactions. This paper will present an overview of the SimCoach project that aims to develop virtual human support agents to serve as online guides for promoting access to psychological healthcare information and for assisting military personnel and family members in breaking down barriers to initiating care. The SimCoach experience is being designed to attract and engage military Service Members, Veterans and their significant others who might not otherwise seek help with a live healthcare provider. It is expected that this experience will motivate users to take the first step – to empower themselves to seek advice and information regarding their healthcare and general personal welfare and encourage them to take the next step towards seeking other, more formal resources if needed.

Civilian Psychologists in an Army Culture: The Ethical Challenge of Cultural Competence

The Army represents a discrete cultural group with unique features of language, manners, norms of behavior, and belief systems. Cultural competence, traditionally applied to the treatment of ethnic and racial minorities, is also essential for the ethical treatment of Army personnel. We describe some of the challenges and opportunities that non-veteran civilian psychologists may experience when conducting psychological assessments, treatment, and command consultations in an Army medical treatment facility. In addition, training procedures, including Army cultural exposure experiences, training on relevant regulations, observation of experienced Army psychologists, and mentoring, are recommended to assist civilian psychologists in obtaining the knowledge and skills required for ethical practice.

The "PE coach" smartphone application: an innovative approach to improving implementation, fidelity, and homework adherence during prolonged exposure.

Prolonged exposure (PE) is an empirically supported treatment that is being disseminated broadly to providers in the Department of Veterans Affairs and Department of Defense. Innovative methods are needed to support the implementation, dissemination, and patient and provider adherence to PE. The PE Coach is a smartphone application (app) designed to mitigate barriers to PE implementation. PE Coach is installed on the patients phone and includes a range of capabilities for use during the PE session and after each session to support the treatment. Functions include the ability to audio record treatment sessions onto the patients device, to construct the in vivo hierarchy on the device, to record completed homework exercises, to review homework adherence, and to track symptom severity over time. The app also allows sessions and homework to be scheduled directly in the app, populating the device calendar with patient reminder notifications. In the final session, a visual display of symptom improvement and habituation to items on the in vivo hierarchy is presented. These capabilities may significantly improve convenience, provider implementation and adherence, and patient compliance with treatment. Future research is needed to test whether PE Coach is useful and effective.

Confirmatory factor analysis of the posttraumatic growth inventory with a sample of soldiers previously deployed in support of the Iraq and Afghanistan wars

Research has documented the impact of combat trauma on psychological functioning but less is known about the measurement of positive changes after military deployments. This study examined the factor structure of the Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996) on a sample of active duty soldiers (n = 3537) exposed to combat in Iraq or Afghanistan. Confirmatory factor analyses (CFA) were conducted to test a 5-factor model and a single higher-order factor model. CFA results indicated that both models fit the data equally well and provide support for using both the whole scale and a multidimensional scale. The use of the PTGI in military research and the limitations of the current study are discussed.

Virtual reality exposure therapy for the treatment of anxiety disorders: An evaluation of research quality

Randomized controlled trials (RCTs) support the effectiveness of virtual reality exposure therapy (VRET) for anxiety disorders; however, the overall quality of the VRET RCT literature base has yet to be evaluated. This study reviewed 27 VRET RCTs and the degree of adherence to 8 RCT research design criteria derived from existing standards. Adherence to the study quality criteria was generally low as the articles met an average 2.85 criteria (SD=1.56). None of the studies met more than six quality criteria. Study quality did not predict effect size; however, a reduction in effect size magnitude was observed for studies with larger sample sizes when comparing VRET to non-active control groups. VRET may be an effective method of treatment but caution should be exercised in interpreting the existing body of literature supporting VRET relative to existing standards of care. The need for well-designed VRET research is discussed.

Soldier evaluation of the virtual reality Iraq

Repeated combat deployments to Iraq and Afghanistan are resulting in increased rates of posttraumatic stress disorder (PTSD) among military personnel. Although exposure therapy is an effective treatment for this disorder, some personnel do not significantly respond to treatment, possibly due to poor activation of the trauma memory or a lack of emotional engagement during therapy. In addition, some service members do not seek mental healthcare due to treatment stigma. Researchers recently developed a virtual reality (VR) Iraq to attempt to improve activation of the traumatic memory during exposure therapy and to provide a treatment approach that may be more appealing to some service members, relative to traditional face-to-face talk therapy. Initial validation of the application requires an assessment of how well it represents the experiences of previously deployed service members. This study evaluated the realism of the VR Iraq application according to the subjective evaluation of 93 U.S. Army soldiers who returned from Iraq in the last year. Those screening negative for PTSD used and evaluated a VR tactical convoy and a VR dismounted patrol in a simulated Middle Eastern city. Results indicated that 86% of soldiers rated the overall realism of the VR convoy as ranging from adequate to excellent. Eighty-two percent of soldiers reported adequate-to-excellent overall realism of the city environment. Results provide evidence that the VR Iraq presents a realistic context in which VR exposure therapy can be conducted. However, clinical trials are needed to assess the efficacy of VR exposure therapy for Iraq veterans with PTSD.