April 30, 2013
© Stars and Stripes
By Matthew M. Burke
Former Army Sgt. Melissa Cramblett was once again pitched in battle against a tenacious enemy fighter. Her heart raced as she tried to save fellow soldiers from falling.
“I’m going to kill this mother[expletive],” she said to herself as adrenaline coursed through her veins.
Cramblett could put down the controller when violent combat video games like “Call of Duty: Black Ops” got to be too much, but it wasn’t so easy to flip the switch on her post-traumatic stress symptoms, which worsened each time she played.
She suffered anxiety and took her anger out on her family. She couldn’t sleep, but when she did, she was constantly haunted by a solider she knew who had been decapitated in an IED attack in Iraq in 2004. The soldier had been in the vehicle behind her; it was a devastating loss. Now, despite being a few years removed from the battlefield, she was back in Iraq and his bloodied body was standing over her.
“I can’t be in the same room [with someone playing],” she said of the increasingly realistic and violent crop of combat video games, some of which are developed with the help of active-duty and retired special operations troops. “It gives you that adrenaline rush that makes you feel like you’re back there.”
Cramblett has since asked her husband to get rid of the videos at home and she warns servicemembers with PTSD to stay away from them through her work with veterans groups Stay Strong Nation and the Veterans Who Care Foundation.
“I know I’m not the only one suffering from those games,” she said from her civilian job at a recruiting battalion in Portland, Ore. “I think it’s dangerous if a servicemember plays if they have PTSD.”
Despite the beliefs of people like Cramblett — and media reports that former servicemembers might have committed suicide after playing the games — violent combat video games remain a popular respite of troops downrange and a connection to their warrior past once they return home.
Mental health experts have cited them for their therapeutic value in exposure therapy, and that same technology is being used on other platforms to address a host of mental health issues, including PTSD and traumatic brain injury.
“They’re fantastic,” said Charles Figley, director of Tulane University’s Traumatology Institute and an expert on traumatic stress resilience, referring to the realistic combat video games. “The benefit [of playing] far outweighs the risks.”
Figley said servicemembers and veterans will experience an elevated heart rate and some will be taken back to their traumatic memories while playing. However, they will realize it is just a game and know that they are safe at home. They can put the controller down and shut the game off whenever they want. This will help them learn to overcome other triggers of PTSD, he said.
“It’s the mastery of the game, but it’s almost like mastering the memories,” Figley said. He believes the games should be required for all servicemembers returning from the battlefield.
Other doctors are unsure, saying that the reaction to the video games depended on the person. The games are most likely not therapeutic by themselves, but could be when coupled with a therapist to help the servicemember emotionally process their memories.
The technological advancements in these games has had a domino effect, improving virtual reality exposure therapy and leading to some groundbreaking research using active-duty military personnel in hopes of treating the signature wounds of the wars in Iraq and Afghanistan.
A virtual battlefield
In the late ‘90’s virtual reality exposure therapy started with Virtual Vietnam, Rizzo said. Small trials had positive results. In 2003, Rizzo had an idea of taking a tactical combat training simulator and turning it into exposure therapy tool. He even built a prototype, but was told it wouldn’t be needed. Then military doctors issued a call to arms regarding PTSD as the wars in Iraq and Afghanistan raged. Rizzo received funding in 2005.
In 2003, Rizzo had an idea of taking a tactical combat training simulator and turning it into exposure therapy tool. He even built a prototype, but was told it wouldn’t be needed.
Then military doctors issued a call to arms regarding PTSD as the wars in Iraq and Afghanistan raged.
Rizzo received funding in 2005 and Virtual Iraq/Afghanistan was launched in 2008.
Virtual Iraq/Afghanistan places the servicemember in the specific scenario of their trauma. They describe the sights and sounds to a therapist at a control panel. The therapist brings them back in time by adding these elements to the virtual environment and feelings and reactions are dealt with in real time, while the wounds are once again raw.
Equipment includes a head-mounted display with a screen for each eye; an orientation head tracker, so head movements are replicated in the virtual environment; a mock M4 rifle with a joystick; a bass shaker platform that can replicate the idle of the Humvee or an explosion; headphones and a scent machine.
Consider this: The patient is in the turret of a Humvee next to his buddies. A helicopter lands nearby. He hears morning prayers and smells garbage or burning rubber. An insurgent shoots a rocket-propelled grenade, an IED or a vehicle explodes. He jump out of the Humvee and goes through an Afghan village. Guns fire; mortars drop all around him. PTSD kicks in. The therapist discusses his memories, forcing him to confront the past. When nothing tragic happens, the anxiety and other symptoms have been known to dissipate.
“There is a lot of guidance from the therapist,” Rizzo said. “It’s hard medicine for a hard problem.”
The departments of Defense and Health and Human Services are conducting what is being called the highest quality scientific evaluation on virtual reality exposure therapy at Fort Bragg, N.C., and Joint Base Lewis-McChord, Washington, to see whether the therapy is a proven treatment method, according to Greg Reger, one of the study’s lead investigators.
There are 130 servicemembers enrolled. The National Center for Telehealth and Technology study is in its preliminary stages; Ft. Bragg just launched its recruitment.
Reger said virtual reality exposure therapy has never been studied using well-designed research with active-duty military personnel. He hopes the study will answer many questions about virtual reality and exposure therapy.
Does it work? How does it compare to traditional exposure therapy, which usually has servicemembers closing their eyes and imagining their trauma? Could it help emotionally disengaged servicemembers? Does it affect attitudes towards stigma?
“Exposure therapy is a well-accepted form of treatment by the Institute of Medicine, Veterans Affairs/Defense Department Clinical Practice Guidelines, and many others who review the scientific literature,” Reger wrote in an email to Stars and Stripes. “The more innovative approach of using virtual reality in exposure therapy is regarded as promising by those who review the scientific literature but as there are no studies comparing it to traditional PTSD treatments, its relative value remains an open question. … This study will be one of the first to evaluate the traditional form of exposure and virtual reality exposure with active duty military personnel.”
Reger said PTSD is a tricky disorder, because most servicemembers are affected by multiple events from different deployments in different war zones. They might even have questions about which event is causing them problems.
“There is rarely one incident,” Reger said. “Sometimes, treatment will proceed from one memory to a second memory. In a surprising number of cases this is not necessary as the benefits of exposure generalize and are not limited solely to one memory.”
Rizzo is trying to get the word out to servicemembers that in addition to the study, the Virtual Iraq/Afghanistan software is now at 55 sites across the country.
A therapeutic tool
Reger said that virtual reality is not a self-help tool, so he wondered about the value of commercial video games.
“I suspect commercial video games function in different ways for different servicemembers,” Reger said. “As it relates to PTSD treatment, the use of simulation is in the service of therapeutic exposure — this is important. For exposure to be effective treatment, it needs to help the servicemember activate and emotionally process their memory. There are key components to facilitating therapeutic exposure for PTSD and this is provided by trained clinicians.”
Figley said that today’s generation loves video games and that they are a great stress reducer. Rizzo said that at the very least, better graphics have helped push along virtual reality and made it a more effective therapeutic tool.
At Camp Nathan Smith in Kandahar province, Afghanistan, Navy Lt. Calvin Warren, 26, of Aurora, Ill., sat down to play video games two or three times a week between missions with the Kandahar Provincial Reconstruction Team.
Troops at the camp gathered in twos or threes or spent time alone in front of gaming console. Sports, fighting, racing or first-person shooters were among the most popular games — including the “Call of Duty” titles, “Madden NFL 2013” and “Dishonored,” a bloody first-person assassin game.
“Video games run the gamut from being very popular with some troops to others not having any interest in them at all,” Warren said. “The games are purely for stress relief and as a way to temporarily not focus on your surroundings.”
To relieve stress, Warren prefers slower-paced strategy games that require thinking to accomplish a task or solve a puzzle — like “Neverwinter Nights 2,” “Sid Meier’s Civilization V” and “Warcraft III.” But he said there is “something cathartic about just blowing away wave after wave of Nazi zombies” in “Call of Duty: Black Ops.”
“The guys do play these games a lot,” Warren said. “But there is so much focus, and rightly so, on positive identification, and situational awareness out here, that sometimes these games just give you a chance to destroy large hoards of enemies, towns and anything else that stands in your way without the mess, heartache and counter-effectiveness to the mission that would accompany it in a real-life scenario.”
Warren said that he is surrounded by professionals and the violence of the games stays in the gaming console.
Developing a new treatment
Because of the popularity of video games with the troops, researchers at the U.S. Army Medical Research and Materiel Command’s Telemedicine and Advanced Technology Research Center devised a plan to use them to monitor cognitive performance by assessing the reaction time and attention of servicemembers whose mental performance may be impaired by PTSD, TBI or other issues, according to Ashley Fisher, the center’s Resilience Portfolio Manager.
The center recently saw Army Small Business Technology Transfers of $100,000 each to Empirical Technologies Inc., Aptima, Inc. and Vista Life Sciences. These companies are tasked with making games for mobile platforms that focus more on the physical wiring of the brain, testing servicemembers’ cognitive function and gathering neurocognitive data, according to the contract.
Empirical Technologies plans a racing game and Aptima plans a game that will improve cognitive function in patients with TBI. In that game, players will be cast as a cyberspy tasked with completing cognitive exercises to infiltrate a living organic computer and defeat a rival.
“The intention is to develop a compelling game that soldiers want to play and can track and monitor cognitive status in a way that is engaging and fun,” Fisher wrote to Stars and Stripes. “This is a promising concept with some initial promise in the literature.”
The companies have six months to develop a prototype, Fisher said. They will then undergo a review and selection process. Some might go on to Phase II, which will be decided in September. Those selected will receive an additional award of $750,000 for three years of prototype refinement and initial testing.
Fisher said the center was involved with Virtual Iraq/Afghanistan so they are aware that PTSD can be triggered in some by video games. But the popularity of video games cannot be overlooked.
“Certainly any content that reminds someone with PTSD about their trauma can make it worse and must be considered,” Fisher wrote. “The science in this field of ‘therapeutic games’ is really in its infancy."