Jonathan Tissue, 35, returned home from combat missions in Afghanistan and Iraq with invisible wounds. He had been injured twice but was physically mobile. It was his anger at home that made him seem like a different person to his friends and family. Every time he drove by a garbage truck, he became tense, recalling the vehicle-borne improvised explosive device that hit his convoy while overseas.
The doctors at Veterans Affairs prescribed traditional talk therapy for his combat-related post-traumatic stress disorder. For five years, he met with psychotherapists but nothing improved. He became more difficult, irritable, anxious, depressed, with occasional angry outbursts.
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Frustrated, he stopped the treatments but after several years he realized he was no longer the husband or father he once was and wanted to be. This time, VA doctors suggested a new kind of treatment: virtual reality immersion therapy.
With a visor strapped on his head, showing images of burned-out Humvees in Iraqi streets, the treatment would make him relive - visualize - some of his most traumatic memories in a safe environment in an effort to make those memories more manageable.
"I was weirded out," Tissue recalled. "Why would you do that? But, I do play [the video game] Battlefield a lot. So I guess if you put a visor on my head and a cool gun in my hand, maybe it would work."
VR treatments use computer graphics, visual displays and various body motions and sensory inputs to plunge survivors of car crashes and roadside bombings, first responders, and those who suffer from a debilitating phobia back to the moment that started their trauma and fear.
VA has been studying VR therapy - a form of psychiatric treatment known as prolonged exposure therapy - since the late 1990s in an effort to help military personnel deal with trauma. These days, the therapy is gathering support. Recent papers published by the National Institutes of Health suggest a high efficacy rate, although the treatment has yet to be used as a substitute for traditional forms of cognitive behavioral (CBT) or exposure therapy.
It is one of several treatments that have patients revisit emotionally disturbing memories with the guidance of a therapist, including eye movement desensitization and reprocessing (EMDR). Interest in such alternative therapies is being driven by patients frustrated that standard mental health treatments, including "talk therapy" and prescription medications, are not bringing them relief.
Although VR treatment has not been subjected to randomized controlled clinical trials, considered the gold standard for evaluating medical interventions, psychiatrists who work with it say trauma victims often show marked improvement after going through it.
Studies suggest VR treatment may be helpful for treating schizophrenia, dementia, PTSD, substance addiction and some phobias (an early use was for acrophobia - a fear of heights - in 1995). The treatment also has been seen as effective in reducing paranoia, anxiety disorders, persecutory delusions, and hearing or movement limitations in real life.
Few patients quit the treatment after their first or second session - only 3% of patients dropped out of it compared with 27% who underwent exposure therapy in real life scenarios, according to a 2020 review of VR therapies.
Individual VA hospitals began offering the treatment as early as 2007, although there was no broad implementation beyond trials. Today, more than 35 VA sites across the country offer the treatment after clinicians recognized it attracted patients who might otherwise balk at talk therapy.
For Tissue, his first exposure therapy session in February 2020 recalled some of the toughest deployments he had. After placing the headset over his eyes, the therapist asked Tissue to describe the moments in great detail. The therapist then programmed sights, sounds, smells into the VR environment that Tissue would encounter via his headset. His thoughts and words became reality.
"The next thing you know you're sitting in a chair ready to bawl your eyes out," he recalled. After three sessions, he felt emotionally weightless, as though he could breathe again. "After six years of talking with people at the VA, I felt better in three days."
One study of 92 Iraq and Afghanistan veterans and active duty military personnel, who, like Tissue, were suffering from PTSD, found significant decreases in social isolation, depression and anger after six months of VR treatment. But that study also found the virtual reality component alone could not sustain long-term improvements for patients. VR treatment would need to be supplemented with CBT and talk therapy and in some cases with a regular prescription medicine regimen.
One of the authors of that study, Deborah Beidel, who also oversaw Tissue's treatment at the University of Central Florida's UCF Restores intensive outpatients program, said using VR to help people overcome traumas, phobias and fears makes sense experientially and neurologically.
"How you get over your fear of a dog? Well, I've gotta be around a dog," said Beidel, executive director of UCF Restores. "You have to do it for a period of time. There are actually new neuronal connections that are being made in your brain, and what you're learning is that just because a dog bit you once doesn't mean every time you see a dog you're going to get bit. Those new memories become stronger."
VR technology is now affordable - immersive gaming equipment that had cost about $100,000 in the 1990s sells for $100 today, according to the 2020 study - so more people will probably turn to it for mental health and other treatments, VR experts said.
Hunter Hoffman, director of the Virtual Reality Research Center at the University of Washington at Seattle, has developed a VR therapy for burn victims. SnowWorld, a virtual space filled with whites and blues and greens, provides associative memories that may bring back good Christmas memories during an otherwise painful session of wound care.
"The more attention grabbing the [virtual] world is, the more pain reduction" a patient is likely to experience, Hoffman said. He noted that undergoing wound treatment without pain management like virtual reality can oftentimes cause flashbacks to traumatic incidents in patients.
"It's not only distracting you from the pain but also from all these unhelpful thoughts," he said.
Some experts express some caution about VR therapy, saying it is an interesting treatment option that needs to be directed by a therapist and combined with other therapy.
"What there is potential for with VR is if you automate therapy or do some of it remotely, you can increase accessibility," said Daniel Freeman, a professor of clinical psychology at Oxford University and the founder of Oxford VR, which develops automated VR therapies for use by patients at home, without a clinician present. Freeman said that the future of VR treatments is in homebound treatment akin to telehealth, minus the therapist.
"VR is an educational tool," he said.
Andrew Sherrill, an exposure therapist who works with patients with PTSD and obsessive-compulsive disorders at Emory Healthcare in Atlanta and who co-wrote a study on the retention rate of veterans using both VR and traditional forms of talk therapy treatments, said "maybe one day we can develop health care that can help one another without a therapist. We're just not there yet."
For Tissue, however, what exists now helped him put some of his trauma behind him.
"I'm not saying you're 100% better" with VR therapy, Tissue said, but "you're feeling [a] little better about being a human being. You start feeling yourself smiling a bit more, you want to talk to more people, call more family members, rather than alienating them."
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