Chapter 8 Treating Combat-Related PTSD With Virtual Reality Exposure Therapy

Introduction to Clinical Virtual Reality (VR)  An advanced form of human-computer interface that allows the user to interact with and become immersed within a computer-generated simulated environment  VR sensory stimuli can be delivered by using various forms of visual display technology that integrates real ‑ time computer graphics and/or photographic images/video with a variety of other sensory output devices that can present audio, “force-feedback” haptic/touch sensations, and even olfactory content to the user.  An advanced form of human-computer interface that allows the user to interact with and become immersed within a computer-generated simulated environment  VR sensory stimuli can be delivered by using various forms of visual display technology that integrates real ‑ time computer graphics and/or photographic images/video with a variety of other sensory output devices that can present audio, “force-feedback” haptic/touch sensations, and even olfactory content to the user.

Virtual Reality Exposure (VRE) to Treat PTSD  Delivers empirically supported CBT with Prolonged Exposure (PE) in the context of virtual reality.  Imaginal exposure entails engaging mentally with the fear structure through repeatedly revisiting the traumatic event in a safe environment.  The clinician guides and encourages the client to imagine, narrate and emotionally process the traumatic event within the safe and supportive environment of the clinician’s office.  The client can begin to process therapeutically the emotions that are relevant to the traumatic event as well as decondition the avoidance learning cycle of the disorder via a habituation/extinction process.  Delivers empirically supported CBT with Prolonged Exposure (PE) in the context of virtual reality.  Imaginal exposure entails engaging mentally with the fear structure through repeatedly revisiting the traumatic event in a safe environment.  The clinician guides and encourages the client to imagine, narrate and emotionally process the traumatic event within the safe and supportive environment of the clinician’s office.  The client can begin to process therapeutically the emotions that are relevant to the traumatic event as well as decondition the avoidance learning cycle of the disorder via a habituation/extinction process.

The Advantage of Using VRE for PE  Many clients are unwilling or unable to effectively visualize the traumatic event.  VRE addresses this problem by immersing clients in simulations of trauma-relevant environments in which the emotional intensity of the scenes can be precisely controlled by the clinician in collaboration with the client’s wishes.  In this fashion, VRE offers a way to circumvent the natural avoidance tendency by directly delivering multisensory and context-relevant cues that evoke the trauma without demanding that the patient actively try to access his/her experience through effortful memory retrieval. Within a VR environment, the hidden world of the patient’s imagination is not exclusively relied upon.  Many clients are unwilling or unable to effectively visualize the traumatic event.  VRE addresses this problem by immersing clients in simulations of trauma-relevant environments in which the emotional intensity of the scenes can be precisely controlled by the clinician in collaboration with the client’s wishes.  In this fashion, VRE offers a way to circumvent the natural avoidance tendency by directly delivering multisensory and context-relevant cues that evoke the trauma without demanding that the patient actively try to access his/her experience through effortful memory retrieval. Within a VR environment, the hidden world of the patient’s imagination is not exclusively relied upon.

Virtual Iraq/Afghanistan City and Desert Humvee Scenarios* Courtesy of USC Institute for Creative Technologies and Virtually Better,

Virtual Iraq/Afghanistan City and Desert Humvee Scenarios* Courtesy of USC Institute for Creative Technologies and Virtually Better,

Latest Version of Virtual Iraq/Afghanistan Scenarios* Courtesy of USC Institute for Creative Technologies and Virtually Better,

Latest Version of Virtual Iraq/Afghanistan Scenarios* Courtesy of USC Institute for Creative Technologies and Virtually Better,

Latest Version of Virtual Iraq/Afghanistan Scenarios* Courtesy of USC Institute for Creative Technologies and Virtually Better,

Latest Version of Virtual Iraq/Afghanistan Scenarios* Courtesy of USC Institute for Creative Technologies and Virtually Better,

Latest Version of Virtual Iraq/Afghanistan Scenarios* Courtesy of USC Institute for Creative Technologies and Virtually Better,

Latest Version of Virtual Iraq/Afghanistan Scenarios* Courtesy of USC Institute for Creative Technologies and Virtually Better,

Prior to Initiating Treatment With Virtual Iraq/Afghanistan  When a possible referral for VRE is received, the following information should be elicited to make sure this is an appropriate treatment modality for this individual:  Referral source (how they heard about the program) and why specifically they are seeking treatment.  The basic nature of their symptomatology; that is, elicit whether they were diagnosed with PTSD or do a basic screen to identify whether they may have symptoms of PTSD.  The nature of their exposure to the traumatic event.  It is important before scheduling treatment to ascertain if the nature of their trauma seems appropriate for the virtual reality environment  However, do not elicit their entire experience over the phone before the initial appointment.  If one of the VR environments would not be appropriate given the nature of the client’s traumatic event, consider prolonged imaginal exposure without the VR.  When a possible referral for VRE is received, the following information should be elicited to make sure this is an appropriate treatment modality for this individual:  Referral source (how they heard about the program) and why specifically they are seeking treatment.  The basic nature of their symptomatology; that is, elicit whether they were diagnosed with PTSD or do a basic screen to identify whether they may have symptoms of PTSD.  The nature of their exposure to the traumatic event.  It is important before scheduling treatment to ascertain if the nature of their trauma seems appropriate for the virtual reality environment  However, do not elicit their entire experience over the phone before the initial appointment.  If one of the VR environments would not be appropriate given the nature of the client’s traumatic event, consider prolonged imaginal exposure without the VR.

Components of Treatment Sessions  Most treatment sessions will include:  Review of client’s reactions and functioning (15 minutes)  Virtual reality exposure therapy (45 minutes)  Processing of material that emerged during exposure (20—30 minutes)  Assignment of homework for next session or conclusion of session (5—10 minutes)  Other components that may or may not be used:  Breathing relaxation  Cognitive restructuring  Pleasant events scheduling  Most treatment sessions will include:  Review of client’s reactions and functioning (15 minutes)  Virtual reality exposure therapy (45 minutes)  Processing of material that emerged during exposure (20—30 minutes)  Assignment of homework for next session or conclusion of session (5—10 minutes)  Other components that may or may not be used:  Breathing relaxation  Cognitive restructuring  Pleasant events scheduling

Treatment Options/Variations  Recommended:  Begin with VRE alone as the primary treatment component, starting with imaginal exposure to the most traumatic memories matching what the patient describes with the virtual reality.  Alternatively:  Begin with imaginal exposure only for the first one or two sessions, followed by:  gradual exposure to the virtual environments, allowing the client to “wander” and explore the virtual environment while describing aloud any memories triggered by the virtual reality environment for one or two sessions.  and finally, imaginal exposure to the most traumatic memories matching what the patient describes with the virtual reality.  Others prefer to start with imaginal exposure first to the most traumatic memories for one or two sessions prior to initiating VRE.  Recommended:  Begin with VRE alone as the primary treatment component, starting with imaginal exposure to the most traumatic memories matching what the patient describes with the virtual reality.  Alternatively:  Begin with imaginal exposure only for the first one or two sessions, followed by:  gradual exposure to the virtual environments, allowing the client to “wander” and explore the virtual environment while describing aloud any memories triggered by the virtual reality environment for one or two sessions.  and finally, imaginal exposure to the most traumatic memories matching what the patient describes with the virtual reality.  Others prefer to start with imaginal exposure first to the most traumatic memories for one or two sessions prior to initiating VRE.

Session 1  Present session agenda (5 min).  Provide overview of treatment (30 min).  Gather information from patient (35 min).  Breathing retraining (15 min).  Assign homework and end session (5 min).  Present session agenda (5 min).  Provide overview of treatment (30 min).  Gather information from patient (35 min).  Breathing retraining (15 min).  Assign homework and end session (5 min).

Session 1 (continued)  Present session agenda (5 min).  Provide overview of treatment (30 min).  Gather information from patient (35 min).  Why did he/she seek treatment?  What symptoms are most distressing?  Describe their deployment(s).  Some information on the most distressing trauma. If there is a close second, it can be noted and will be the focus of exposure if there’s time for an adequate response.  Other trauma history.  Social situation and any current social stressors.  Occupational situation and any occupational or financial stressors.  Social support and resources they can rely on during this treatment.  Suicidal ideation and contracting for safety.  Breathing retraining (15 min).  Assign homework and end session (5 min).  Present session agenda (5 min).  Provide overview of treatment (30 min).  Gather information from patient (35 min).  Why did he/she seek treatment?  What symptoms are most distressing?  Describe their deployment(s).  Some information on the most distressing trauma. If there is a close second, it can be noted and will be the focus of exposure if there’s time for an adequate response.  Other trauma history.  Social situation and any current social stressors.  Occupational situation and any occupational or financial stressors.  Social support and resources they can rely on during this treatment.  Suicidal ideation and contracting for safety.  Breathing retraining (15 min).  Assign homework and end session (5 min).

Session 1 Conclusion  Homework:  Practice breathing retraining three times per day.  Read “Rationale for Treatment by Prolonged Exposure” handout.  Remind client that the more he or she practices the breathing, the better trained the body will be to relax and to use it when he or she really needs it.  Elicit any questions, doubts, or concerns.  Instill hope and excitement for starting this work together.  Make sure next session time is scheduled; it is okay also to schedule all eight sessions and write them down for client.  Give therapist’s card with contact information.  Give handout on client rationale for treatment by prolonged exposure.  Homework:  Practice breathing retraining three times per day.  Read “Rationale for Treatment by Prolonged Exposure” handout.  Remind client that the more he or she practices the breathing, the better trained the body will be to relax and to use it when he or she really needs it.  Elicit any questions, doubts, or concerns.  Instill hope and excitement for starting this work together.  Make sure next session time is scheduled; it is okay also to schedule all eight sessions and write them down for client.  Give therapist’s card with contact information.  Give handout on client rationale for treatment by prolonged exposure.

Session 2  Review homework (5 min).  Present session agenda (5 min).  Discuss common reactions to trauma and normalize client’s reactions (45 min).  Present detailed rationale for exposure (20 min).  Introduce SUDS Scale (10 min).  Assign homework and end session (5 min).  Review homework (5 min).  Present session agenda (5 min).  Discuss common reactions to trauma and normalize client’s reactions (45 min).  Present detailed rationale for exposure (20 min).  Introduce SUDS Scale (10 min).  Assign homework and end session (5 min).

Session 3  Review homework (10 min).  Present session agenda (5 min).  Present brief review of rationale for exposure (5 min).  Instructions for exposure (10 min).  Conduct exposure (30–40 min).  Process exposure and end session (15–20 min).  Review homework (10 min).  Present session agenda (5 min).  Present brief review of rationale for exposure (5 min).  Instructions for exposure (10 min).  Conduct exposure (30–40 min).  Process exposure and end session (15–20 min).

Session 4  Check-in (10-15 min).  Present session agenda (5 min).  Conduct exposure (30-40 min).  Process exposure (30 min).  End session (5 min).  Check-in (10-15 min).  Present session agenda (5 min).  Conduct exposure (30-40 min).  Process exposure (30 min).  End session (5 min).

Session 5  Check-in (10 min).  Present session agenda (5 min).  Introduce and identify hot spots (10–15 min).  Conduct exposure (30–40 min).  Process exposure and end session (20 min).  Check-in (10 min).  Present session agenda (5 min).  Introduce and identify hot spots (10–15 min).  Conduct exposure (30–40 min).  Process exposure and end session (20 min).

Sessions 6-8  Check-in (10–15 min).  Present session agenda (5 min).  Conduct exposure to hot spot (30–40 min).  Process exposure (30 min).  End session (5 min).  Check-in (10–15 min).  Present session agenda (5 min).  Conduct exposure to hot spot (30–40 min).  Process exposure (30 min).  End session (5 min).

Session 9  Check-in (10 min).  Present session agenda (5 min).  Conduct exposure to entire trauma memory (25–30 min).  Process exposure (15 min).  Review treatment program and patient’s progress (20–30 min).  Termination (10 min).  Check-in (10 min).  Present session agenda (5 min).  Conduct exposure to entire trauma memory (25–30 min).  Process exposure (15 min).  Review treatment program and patient’s progress (20–30 min).  Termination (10 min).

Discussion Question  How are virtual reality exposure and prolonged imaginal exposure for PTSD similar and different?