The flood of behavioral-health problems in the military seems to have peaked. Fortunately, things stayed far from the degeneracy of the late 1960s and early 1970s described by Colonel Robert Heinl Jr. in his 1971 Armed Forces Journal article.
Things are definitely changing for the better.
It is now over two years since the publication of General Peter Chiarelli’s Health Promotion, Risk Reduction, Suicide Prevention Report 2010, also known as the Red Book. This report assessed the health of the force and outlined how improvements could be made. These improvements are trickling in. The seeds of long ago are bearing fruit.
In March, Dr. Albert Rizzo and his colleagues from the University of Southern California‘s Institute for Creative Technologies published the results of their work in the Psychiatric Annals. Their virtual reality (VR) therapy — which is already evidence-based due to its adherence to cognitive-behavioral therapy and exposure therapy models — no doubt has the potential to reach the thousands of patients who have had the most difficult and, dare I say, an impossible time interfacing and benefiting from traditional methods of therapy and mental health care delivery.
Simulation has long held the promise of shaping the mind through virtual experience free from the dangers of the real world. The observations that virtual traumatic experiences had real negative psychological effects were one of the indications for the existence of a complementary phenomenon where virtual safety experiences would have real positive psychological effects.
Indeed, the brain is fairly poor in distinguishing reality from simulation. The effects of the confusion between reality and fantasy were again laid bare when after the 9/11 attacks people with exposure to the World Trade Center collapse on television experienced post-traumatic stress symptoms similar to those who had experienced the events first hand.
Virtual reality therapy takes advantage of these basic interactions in emotional processing to re-associate the memory of a heretofore feared experience with feelings of safety rather than fear through meticulous and skillfully supported recreation of the memory and the immersion of the patient in an interactive process during which his/her memory of the experience is decoupled from fear and linked with feelings of safety and a sense of agency and mastery.
VR therapy should make it possible for the least amenable of patients to find care.
Allow me to narrate the story behind my optimism.
As an Army psychiatrist, like the rest of my colleagues, I faced some uniquely grim and absurd situations in the past 10 years.
Never did I imagine such an onslaught of behavioral problems, functional difficulties, mental illnesses, and stark neuropsychiatric injuries at the outset of my Army career in 1998. This onslaught included the tragedy of traumatic brain injuries, suicides, and homicides along with the patronizing and seemingly “cover-your-ass” screening of fully normal (in every statistical sense of the word) service members.
Over the years, I witnessed not only a change in the number of disordered and mentally ill service members, but also a changing character among the patients.
At the risk of oversimplification, I felt the change in the quantity of mental/behavioral health patients was due to the protracted duration and increasing incoherence of the wars in Afghanistan and Iraq, with their long and repeated mental toll and diminishing returns for nerves spent.
Again, at the risk of describing only the 20,000-foot view, the qualitative issues seemed to me to be related to the reduced resilience of our soldiers as if they were selected from among the “75% of young adults who cannot join the military.”
The patients with my so-called qualitative issues seemed to possess some disadvantageous traits such as insecure attachment style, sensitivity, emotionality, impulsivity, and poor attention, among others. These characteristics do not constitute mental disorders per se but nevertheless predisposed these patients to disciplinary problems which often triggered punitive administrative measures per Army regulations (see section on “Complexity of High Risk Behavior” in the Gold Book, an update of the Red Book).
Worse yet, these characteristics prevented this population’s successful and trusting interface with the military-health system for recovery as evident by their high burden of disciplinary problems. Needless to say, the reaction of the system was far from benign as apparent by the “neglect of soldiers.”
The VR therapy model developed, tested, and implemented at ICT has a far-improved chance of reaching the patient population with my so-perceived disadvantageous traits.
This young patient population naturally lives in a digital soup of overstimulation and distraction, supremely comfortable with social media and internet use for numerous things including healthcare. They appear to trust the internet, easily relate to gaming and simulation, and readily adopt new technologies which sidestep or accommodate their mainstream socially-defined disadvantageous characteristics.
All of these indicators bode well for VR therapy. Indeed, VR therapy should enhance creation of rapport and therapeutic alliance between the therapist and patient.
Although counterintuitive to some, and likely less applicable to the majority of psychiatric patient currently adequately treated through traditional face-to-face therapy, for the group of patients who are at the highest risk for mental/behavioral and recovery problems, VR therapy should be a far less stigmatizing, negative transference provoking, attention demanding, and countertransference inducing mode of therapy.
The VR therapy interface developed and scientifically elaborated at ICT appears to be just the mechanism needed to reach the patients who through no fault of their own are less optimally equipped to fend off behavioral problems and mental illnesses and recover from them once in the grip of the problem or illness. More research should be done to shed light on the patient who should have VR versus the traditional face-the-face therapy.
Artin Terhakopian is a psychiatrist and a major in the U.S. Army, but the views expressed here are his own. In the last decade, he worked at Walter Reed Army Medical Center in Washington, D.C., the William Beaumont Army Medical Center in El Paso, Texas, and the 10th Combat Support Hospital while it was deployed to Iraq. He is currently a student at the Command and General Staff College at Fort Leavenworth, Kansas.