The development of Virtual Iraq from Full Spectrum Warrior

Traditional treatments for PTSD have included pharmacological intervention, psychotherapy, and cognitive behavioral therapy (CBT). The most effective of these has been a specific type of CBT known as prolonged exposure therapy (PE), in which therapists help clients recount the trauma though imagination, or imaginal exposures, which summon acute symptoms that gradually subside during the therapy session. Over the course of several sessions, clients learn to cope with overwhelming triggers, which translates to everyday life. In essence, the process desensitizes clients to the emotional violence caused by PTSD triggers.

With the exception of pharmacology, each type of PTSD therapy has been enhanced by digital technologies in the past decade through computers and mobile devices that provide video and interactive treatment, therapeutic video games, and collaborative multimedia storytelling; biofeedback; and virtual reality (Clough & Casey, 2011; Coyle, Doherty, Matthews, & Sharry, 2007). Most of these treatments emulate face-to-face therapy, but virtual reality has progressed into a spectacular experience, in which "the sense of immersion or presence […] separates virtual reality from various other forms of communications or technologies" (Clough & Casey, p. 286). Virtual reality is a computer-simulated environment delivered through multimodal devices, most commonly consisting of a head mounted visual display piece and a body suit, sometimes including tactile feedback, sound, and scent. Unlike a movie, the computer interprets the user's head motions through a tracking system, thus making the experience interactive, plus it is possible for the computer operator—in the case of therapy, the therapist—to improvise the event. As a multisensory experience that is perceived as real through technological mediation, virtual reality exposure therapy (VRT) is considered in vivo (video in, video out) and realistic compared to traditional PE, which is imaginal and, hence, imaginary. As one VRT client explains, "When it's only visual, it's not really real—it's just a video game—but when the ground starts vibrating and you smell smoke and hear the AK-47 firing, it becomes very real" (Halpern, 2008, para. 15). Evidence shows that VRT is more effective than PE, in part because some people who experience PTSD are unwilling or unable to recall their trauma (Rizzo et al., 2006), but VRT has been fairly expensive until the last several years, during which the price of virtual reality hardware has decreased.

In 1997, academic researchers instituted an experiment using a program, which it called Virtual Vietnam (Rizzo et al., 2006), to treat longstanding combat-related PTSD in Vietnam veterans. Virtual Vietnam was proven effective in 1999 (Rothbaum et al., 1999) through a case study of a client for whom other therapies had failed. A few years later, the idea for Virtual Iraq came to Rizzo (Rizzo et al., 2006), who had ties to Virtual Vietnam developers and who conveniently worked for the Institute for Creative Technologies, which developed Full Spectrum Warrior and Full Spectrum Leader.

I was working on a talk about virtual reality, just sniffing around the Internet, and I saw this link for the video game Full Spectrum Warrior […] I said, "Oh, my God, that's Iraq!" It was instant. I thought we should take this game and run it in a head-mounted display right out of the box, for therapy. (A. Rizzo, as cited in Halpern, 2008, para. 17)

Rizzo contacted Virtual Vietnam programmer Jarrell Pair, and by February, 2004 they had assembled a prototype. Shortly after Hoge et al.'s (2004) findings of alarmingly high PTSD rates among Iraq War veterans were reported, the Office of Naval Research solicited ITC and Rizzo to develop the Virtual Iraq program (Rizzo et al., 2006), pledging financial support (Halpern, 2008; Rizzo et al., 2010). ICT developed Virtual Iraq by repurposing graphic assets from Full Spectrum Command and FSW as a cost-effective VRT application for treating recently redeployed veterans from Iraq and Afghanistan who were diagnosed with PTSD (Rizzo et al., 2006). As of 2010, Virtual Iraq was being implemented and researched at over 40 military and university sites (Rizzo et al., 2010; Rothbaum, Rizzo, & Difede, 2010); the project has since been updated and renamed Bravemind 4.

In VRT sessions, Virtual Iraq is controlled by a licensed therapist who has been trained to control the environment, gradually exposing clients to stressful triggers specific to the client. Rizzo et al. (2006) explain that Virtual Iraq includes six Middle East scenarios familiar to soldiers. Each scenario can be adjusted for day or night, weather conditions, and illumination of lights. Five user perspectives can be chosen for a given scenario, such as walking alone, with another soldier, with a patrol group, inside a Humvee (Figure 3), and so on. There is also a "Wizard of Oz" (para. 11) screen for the clinician, which depicts the scenario, input prompts, and real-time data on the client's vital signs. In addition to these visual features, the environment incorporates scented sprays, including burning rubber, body odor, diesel fuel, and gun powder (para. 7), and vibrations to emulate vehicular movement and explosions. The client holds a replica of a rifle to make the situation feel real, but the gun cannot be fired in the virtual environment.

Figure 3. Pictured above is a scene from a Bravemind therapy session. Two soldiers sit inside of a smoky Humvee. The driver is bleeding badly from multiple, presumably fatal gun wounds; the other soldier, representing the client, looks at him from the back seat. Used with permission, ©University of Southern California Institute of Creative Technology.

Problematic o/missions in the literature on Virtual Iraq.

Most of the scholarly literature on Virtual Iraq has been internally authored by Rizzo and colleagues, who assess their project as successful according to a medical model perspective of disability. The medical model, which has been thoroughly critiqued in Disability Studies literature, views disability in clinical terms, as a problem necessitating medical intervention and cure. In terms of clinical efficacy, Virtual Iraq has been quite successful. The initial open trial involved recently deployed military personnel who had been treated unsuccessfully for PTSD using other methods (Yeh et al., 2009), and 75% of those who completed the study no longer met diagnostic criteria for PTSD (Rizzo et al., 2010), with 80% making significant gains and reporting anecdotal evidence of improvement (Yeh et al.). Rizzo and colleagues have been careful not to overstate the clinical success of Virtual Iraq, noting that some who registered for the research project failed to show up, and some quit before completing it (Rizzo et al., 2010; Yeh et al.). They also cite numerous reports that indicate a steady increase of PTSD and they discuss the health care and economic implications of this crisis (Rizzo et al., 2010). In support of their project, Rizzo et al. (2006) hypothesize that Virtual Iraq is successful because clients grew up with gaming and are more comfortable with and attracted to VRT compared to talk-based therapy, but they neglect to mention the program's masculine cache, or the stigma of traditional therapy which it counteracts (Halpern, 2008). For example, a U.S. Marine veteran dubbed "Travis Boyd," who successfully completed VRT, stated,

I didn't want to have it on my military record that I was crazy. […] Infantry is supposed to be the toughest of the tough. Even though there was no punishment for going to therapy, it was looked down upon and seen as weak. But V.R. sounded pretty cool. They hook you up to a machine and you play around like a video game. (Halpern, 2008, para. 13)

As Boyd's interviewer asserts, "Telling his buddies that he was going off to do V.R. was a lot easier than telling them he was seeing a shrink" (para. 13). Indeed, Hoge et al. (2004) found that only 23%—40% of Iraq and Afghanistan war veterans who probably had mental disabilities sought mental health care, largely due to stigma. The data outside of VRT research suggest that ableist stigma promoted within military culture escalates PTSD, provokes violence by soldiers with PTSD, and hinders treatment. And despite the cost-effectiveness of Virtual Iraq, Rizzo et al. (2010) clarify that the system is still expensive and that it can only be used by highly trained clinicians. Predictably, they recommend expanded use and further study of Virtual Iraq, including using the tool for assessing PTSD potential prior to deployment; for stress resistance training; for postdeployment reset training; for screening all returning soldiers for PTSD; for comparing different service branches in terms of susceptibility for PTSD; for neuroscience brain imaging; for use combined with psychopharmacology; and for improving Virtual Iraq per ongoing research. Their recommendations, while technically appropriate and amicable to their audience of clinicians and corporations that support their work, are steeped in an ableist, medical model tradition. The primary aims of Rizzo and colleagues have been to eradicate PTSD symptoms through VRT, thus restoring the client to an able-bodyminded state, or to precondition clients to trauma thus rendering them more able-bodyminded. Furthermore, Virtual Iraq is promoted as a relatively masculine, and therefore acceptable, method of treatment, thus bolstering the ableist sentiment that mental disability and treatment are effeminate, weak, and ultimately signs of personal failure. This discourse ignores the complexity of the PTSD treatment process, in which clients come to terms with their disability by confronting it rather than denying it.

The most troubling research mission of VRT, from a critical Disability Studies perspective, is outlined in Rizzo et al.'s (2006) paper for the 2006 NATO Advanced Research Workshop to the Diagnosis and Treatment of Posttraumatic Stress Disorder. After explaining that health care expenses for soldiers with PTSD is 60% higher than average, the authors suggest,

The military could also benefit economically by way of reduced "turnover" of soldiers with mild PTSD. These personnel might be more likely to reenlist if their mental health needs were addressed soon after combat in a progressive manner via early VR assessment and treatment. As well, such a VR tool initially developed for exposure therapy purposes, offers the potential to be "recycled" for use both in the areas of combat readiness assessment and for stress inoculation. Both of these approaches could provide measures of who might be better prepared for the emotional stress of combat. (para. 17)

Rizzo et al.'s mission to utilize Virtual Iraq as a quick-fix to send soldiers back into combat and as a tool for stress inoculation is both problematic, from a mental health standpoint, and ironic, in the context of recycling. After all, the Vitual Iraq program is already "recycled" from games that are misleading in terms of disability, by presenting war as an exhilarating activity free of consequence. As such, the overarching clinical mission of Virtual Iraq is to mitigate damage that in some cases was spawned in the games of its graphic ancestry. Furthermore, a consequence of Rizzo et al.'s attention to economy is omission of attention to PTSD as disability, and the serious problems that have occurred. For instance, Matthew Marino's PTSD was misdiagnosed as anxiety and he was sent on another tour (Benjamin & de Yoanna, 2009; see de Yoanna & Benjamin, 2009a). Virtual Iraq has been spared the critical scrutiny of America's Army and retail violent video games, perhaps because it is sanctioned as therapeutic and potentially curative under the medical model of disability, which is why I have examined their close relationship.

Another omission from the academic research on Virtual Iraq is qualitative data from the veteran research participants with PTSD—what "anecdotal evidence" (Yeh et al., 2009) did they report? Did they appreciate the therapy and recommend it to peers? As participants maintained positive gains after three months (Yeh et al.), did they feel and identify as non-disabled? Would those who were successful in treatment consider another deployment? Do veterans treated for PTSD wish they would have experienced pre-combat virtual reality simulations? Having experienced PTSD, do they regret enlisting? Do "successful" VRT clients remain somewhat disabled? Did they and fellow military personnel receive adequate care? Has PTSD changed who they are, or the ways in which they conceptualize mental disability or masculinity? What influence did violent video games, including America's Army and Full Spectrum Warrior have in their decisions to enlist—and do they still play such games?

Partial answers can be found in popular media, Finley's (2011) anthropological study of veterans with PTSD, unpublished research, and social networking sites, such as YouTube, in which people discuss things related to combat PTSD and Virtual Iraq. Beyond Travis Boyd's testimony cited above, he also described how distressing and emasculating the treatment process was:

Each time [the therapist] added something, like an I.E.D. going off, or a plane flying over, I'd become more emotional. We'd do it over and over, and it would become easier, and then she'd add something more and the same thing would happen. I'd talk for forty minutes about this one five-minute thing. […] I'd be shaking. When it was over, I'd go home and cry. (Halpern, 2008, para. 15)

At the conclusion of the interview, Boyd summarizes that "[m]ost of the intrusive thoughts have gone away," and that "[y]ou never really get rid of P.T.S.D., but you learn to live with it" (Halpern, para. 36). These sentiments are echoed by Master Sgt. Robert Butler, a Marine combat cameraperson, in a video featured on the defunct disability social networking website, www.disaboom.com, which has continued to appear on other venues, including YouTube (http://www.youtube.com/watch?v=CAk7MxaEICs). Butler recounts a chaotic incident on a Father's Day in which his patrol unit destroyed a water truck containing a 16-year-old boy and his father. A year later, Butler was home, unable to carry out simple tasks, when he was diagnosed with PTSD by the division psychiatrist. He recalls his reaction to the diagnosis as "the last thing on the planet I wanted to hear." After two months of therapy, he applauds VRT, stating "I mean, am I a hundred percent better? No, I wouldn't say I was a hundred percent better. But I do have my life back." He credits the therapy for saving his marriage and possibly his life. A similar story appears on the news website Salon (http://www.salon.com), which frames a discussion of Virtual Iraq around "Kevin Smith" (pseudonym), allegedly the "first Iraq veteran who has completed the treatment to speak about it publicly" (Zimmerman, 2007, para. 7). Despite still not being able to confront some memories, which Smith asserted "are too much for me … I don't want to relive them again" (para. 17), he is touted as "one of the lucky ones" (para. 21) who has now been successfully treated. Most third-person accounts spin discussions of Virtual Iraq through a medical model lens that champions the program and its developers for helping soldiers to overcome their disability through courage and good fortune.

Zimmerman's (2007) article stands out in its attention to the most important omission within the literature on VRT, the U.S. military's care for disabled servicepersons and veterans. After billing Kevin Smith as a lucky one, Zimmerman argues that mental health is the largest unmet need in veterans' medical care, fueled by bureaucracy and, in the case of the Army, the intentional underreporting and underdiagnosing of PTSD to save money. This crisis has been well-documented since Salon's 2009 exposé, "Coming Home: The Army's Fatal Neglect," which revealed preventable suicides, homicides, and drug overdoses of soldiers stationed at Fort Carson, Colorado Army base. The series identified a "record-setting pace" of Army suicides in 2008 and early 2009 (Benjamin, 2009), and several homicides, which the Army denied as corresponding to combat stress, despite evidence (de Yoanna & Benjamin, 2009b). Most of the "Coming Home" articles emphasize untreated, combat-related PTSD as the major contributing factor toward this violence, citing two main reasons for untreated PTSD: harassment and underdiagnosing. Soldiers with symptoms of mental stress were frequently "ridiculed or otherwise discouraged from seeking help" (de Yoanna & Benjamin, 2009b, para. 3; see Benjamin & de Yoanna, 2009d). Braswell and Kushner (2012) have linked this phenomenon to masculine ideologies promoted within the U.S. military, arguing that military suicides are often the result of excessive social integration into military culture, the values of which are mirrored in the scripts and actual gameplay of violent video games including FSW and, especially, America's Army. Bolstering Braswell and Kushner's argument, several "Coming Home" case studies (Benjamin & de Yoanna, 2009a, 2009b, 2009c) describe soldiers with PTSD being assaulted, berated, blamed, and intentionally misdiagnosed for their condition. In one case, a psychiatrist under surveillance admitted to following commands to misdiagnose PTSD and traumatic brain injury (de Yoanna & Benjamin, 2009a), and in another case, it took an attempted suicide and a private psychiatrist's diagnosis of PTSD before an Army psychiatrist finally changed a soldier's diagnosis to chronic PTSD (Benjamin & de Yoanna, 2009b).