Phobics to Firefights

Developed by Georgia Tech Professor Larry Hodges and his colleagues at Emory University and Atlanta’s Veterans Affairs Medical Center, “Virtual Vietnam” builds on the idea of treating phobias by repeatedly exposing phobics to what scares them, eventually desensitizing them to their fears. For example, a counselor might take someone with a fear of heights to ever-higher perches—until height no longer triggers a panic response.

Several years ago, Hodges wondered if virtual reality could replicate the actual experience of height adequately to achieve the same effect.

“We had no idea whether someone afraid of heights in the real world would be afraid in the virtual world,” Hodges says. “And if they were afraid, would they get over it and habituate to it? In ’93, it turned out that all these things were true—that the therapy was successful.”

That success led to virtual worlds for treating a fear of flying, spiders or public speaking—all now successful commercial products. But creating the same tool to treat those Vietnam veterans with PTSD took Hodges’ virtual concept to a challenging new level.

“We were interested in doing something that was more extreme than phobias because we knew we were successful there,” Hodges says. “We were looking for how far we could carry this.”

Hodges’ team created several three-dimensional visual scenes instantly recognizable to Vietnam veterans, from the killing grounds of a “hot” landing zone to air rescue. To enhance the images patients see through a virtual-reality headset, they added another dimension, the chaotic din of battle. Patients in the virtual world are surrounded by the chatter of enemy weapons, the unmistakable whiz of an AK-47 round that just missed its mark, the welcome rumble of the ubiquitous Huey coming to take them out of harm’s way—all thunderously amplified to remarkably reproduce the conditions of combat.

The effects on veterans whose buried memories are reawakened, Hodges relates, can be chilling:

Tech professor Larry Hodges and a team from Emory University and the Atlanta VA Medical Center have created a “virtual Vietnam” to help treat the lingering problems of soldiers who served in Vietnam. By viewing images reminiscent of actual combat experiences—complete with battle sounds—soldiers may be able to conquer their phobias.

“There was one patient who was a tank commander. Everybody in his tank was killed but him. He was left for dead, but he survived. He relived that in the virtual environment. We thought he was going to take the platform apart. He was seeing the other tanks; he was giving commands to all his men and calling them by name. It was probably the most spine-tingling virtual environment scenario I’ve ever seen.

“Another one was a bulldozer operator who actually buried a village they wiped out. He was completely different; he never got excited; he just talked in a monotone the whole time. Real carefully he described digging the grave, putting the bodies in, throwing the lime on, knocking out their gold teeth. It was disturbing in a different way because he was so matter-of-fact going through all this.”

Trapped in Combat

The point, says VA psychologist Dr. David Ready, himself currently using Virtual Vietnam to treat patients, is that veterans with PTSD don’t just remember traumatic events—they relive them. And that goes on for as long as the victim continues to avoid horrific memories, as many as 70 years in a case study of a World War I veteran.

Ready uses the analogy of a frightened movie-goer to help explain the phenomenon.

“If every time the movie comes up to the part where the guy gets out the knife, and you run out of the theater every time because it frightens you, then your fear will actually build up with time,” he says. Eventually it can reach the point, as it does with PTSD, that an everyday stimulus can prompt sufferers to re-experience events. For instance, a victim hearing the sound of a helicopter going over may experience mortal fear and retreat from that reality however possible, over and over again.

“How do you interrupt that cycle? You have to help them not avoid working through it by going back and getting in touch with it again. It’s like if you go back to that film you’re running out of and make yourself sit through it, and sit through it. After a while it just doesn’t scare you as much.”

What’s the goal of virtual exposure therapy: to make bad memories just bad memories.

“When your friend dies and blows up all over you, it’s always going to be a bad and terrible thing. But whether or not it is traumatic, whether or not you re-experience it, whether or not you feel mortal danger when you think about it, that can change.”

The Long Boat Ride Home

PTSD is neither new nor specific to Vietnam veterans, although it has only recently been diagnosed and characterized scientifically. During the Civil War, it was called “Soldier’s Heart,” and in World War I “shell shock.” According to scholarly works by those involved in developing Virtual Vietnam, symptoms of the condition can be found in ancient mythology or the works of Shakespeare. Ready says even World War II’s most-decorated hero, Audie Murphy, suffered from PTSD.

But it is more prevalent among Vietnam veterans, Ready theorizes, because unlike World War II—when soldiers returned to a hero’s welcome—Vietnam vets found themselves branded by the war’s unpopularity.

“I went over there to do my duty,” says PTSD patient Randy Kemerly. “I wasn’t over there doing something wrong. When I came back, there wasn’t no one to talk to about what I just went through. After a while you just learn to shut up and suck it up and hold it in. It gets to be heavy after a while.”

Also unlike World War II, when veterans had a weeks- or months-long boat ride home during which they could decompress, share their horror with others who experienced the same thing and readjust to civilian life, Vietnam veterans were abruptly plucked from combat and jetted back home.

“If you’re in a combat zone, a lot of the symptoms of PTSD—being hyper-vigilant, watchful every minute or suspicious—are things you need to survive. But they are very destructive in civilian life,” Ready says.

“These guys were put on jets, and they were back in the United States in 48 hours, sometimes less. They were given a pass as soon as they got back home. They were supposed to adjust from fighting for their lives to being an everyday guy in a short time. Many of them got stuck in combat mode and stayed there.”

As a result, many PTSD victims are extreme perfectionists who become very upset when little things go wrong because they know that little things got people killed in Vietnam. Others become workaholics to avoid their memories, or become addicted to alcohol or drugs—all to deal with the traits they developed for survival in Vietnam but were unable to discard.

“The more vulnerable they feel, the more volatile they are,” says VA psychologist David Ready. “So for a lot of guys, PTSD is getting worse because they’re no longer able to control the world around them.” Tech researchers, he adds, are to be commended. “They’ve really invented something new—the best psychotherapy-related software in the world.”

At one of Ready’s group sessions, one man was very angry because someone else on the bus he had ridden to the hospital was listening to music through headphones—he felt he had to watch out for both of them. Another, in a wheelchair because pneumonia left him weak, spoke with great bravado to avoid feeling out of control.

Treating the Spectrum of Symptoms

The wide variety of symptoms and the expectation that Vietnam veterans would simply get better with time made PTSD difficult to recognize, harder to treat. Only in the past decade has the affliction really been accepted as an illness, and treatment still is often a matter of trial and error.

Doctors are getting better at it, slowly, explaining their enthusiasm for virtual therapy.

“Part of the therapy is just getting them to talk about their Vietnam experiences. A lot of these guys, when you see them outside the virtual environment, they’re depressed. It’s very hard to get them to talk about their experiences at all,” Hodges says. Once inside the virtual environment, memories become more detailed and horrific events less fearsome.

“The more I got into the stories, and the more organized the stories became for me again, the more details that I started remembering again, the better I would feel after it was over. I would feel relaxed and kind of cleansed,” Kemerly says.

Cleansing? Yes. Helpful? Yes. A cure? No, Ready says.

“This helps with certain symptoms. Those who experience it say it helps to reduce the nightmares. It doesn’t cure PTSD. We don’t know how to cure PTSD. No one does.

“But it’s part of the management. It’s part of them moving forward. Some are willing to tolerate the pain of dealing with this so that they may suffer less because of it. It’s one more weapon in our arsenal. But is it a panacea? No.”

A World Out of Control

The truth is other new treatments such as virtual reality must be developed, and developed quickly. Like everyone else, as Vietnam veterans age, they become more vulnerable in the real world, worsening their conditions.

“The more vulnerable they feel, the more volatile they are,” Ready says. “So I think for a lot of guys, PTSD is getting worse because they’re no longer able to control the world around them. The guys with PTSD want to control everything because they have been in the world out of control.”

To that, no end is in sight. Continuing world crises such as Somalia and Kosovo are creating a growing population of PTSD victims worldwide, and the real price of war is tallying upward at dizzying speed. From Vietnam alone, estimates of PTSD victims range from 425,000 to 830,000.

But the options are growing as well. In the 15 years he has worked with veterans, Ready says the number of programs to treat PTSD has grown from a mere dozen to 136. And he has high praise for those such as Tech’s Hodges and Emory’s Barbara Rothbaum, who are pioneering new treatments and technologies.

“They’re to be commended,” he says. “They’ve really invented something new, and Georgia Tech is at the forefront of it. Georgia Tech is producing through Larry Hodges the best psychotherapy-related software in the world that I’m aware of, and in some areas, the only virtual-reality based software in the world.

“If it weren’t for them, we wouldn’t be doing this. We’re the first and only at this point in time, but a lot of other people are going to be doing this in the future.

“And these guys deserve it. They served their country when others ran away. They deserve honor for that.”