When a Veterans Affairs therapist first suggested that Chris Merkle try a virtual reality simulation that would mimic his days in combat, he was horrified. “I was like, you want to put me in a virtual world, reliving my worst days, my worst nightmares?” he said.
It was the winter of 2013, and after three tours in Iraq and four in Afghanistan, Mr. Merkle had spent years struggling with the invasive symptoms of post-traumatic stress disorder. He felt constantly on edge, bracing for an attack. He got angry easily. He avoided thinking or talking about his time as a Marine; he tried traditional talk therapy, but didn’t feel ready to discuss his past.
Months later, after his symptoms intensified and he felt desperate for a salve, he decided to give virtual reality exposure therapy a try at a Department of Veterans Affairs hospital in Long Beach, Calif. The treatment uses V.R. technology to immerse a patient in a three-dimensional environment that mimics a traumatic memory. He strapped into a headset and sank into the past.
The details in the simulation were extremely precise, Mr. Merkle said: the military-issue truck, the weight of the model gun in his hand, the dark swath of sand in the night. He narrated one particularly troubling incident out loud to a clinician, who adjusted the simulation as he spoke. “I was seeing that person shooting at me, that I hadn’t thought about in 10-plus years,” he said. His muscles tensed. His heart raced. He was terrified.
“My body was physically reacting, because my mind was saying, this is happening to us.” But when he took the goggles off, he said, the sense of accomplishment became its own form of comfort. For years, his memories had terrified him. Confronting the past in V.R. proved to him that he could survive revisiting his memories. “That was the biggest leap,” he said.
After about seven runs through the simulation, Mr. Merkle started uncovering fragments of memory his mind had blacked out, which is a common response to trauma. He remembered the name of the soldier who had been next to him in a truck during combat. He remembered the clear feeling that he was going to die. Mr. Merkle walked out in the hall after he was done, grappling with what his brain had revealed.
He felt like he was in a fantasy novel, he said. As he left the session, he imagined that “there was this black smoke pouring out of my mouth, oozing out of me. Like this evil, for lack of a better word for it, was slipping out” of his body. He got to the parking lot and sat in his car for an hour. The treatment was working, he thought. He was less scared of his memories, less scared of himself. He was getting better.
Why V.R.? Why Now?
The most significant disorders that virtual reality therapy has shown success in treating — PTSD, anxiety, phobias — are on the rise. An April survey by the Centers for Disease Control and Prevention cited significant increases in respondents showing symptoms of anxiety disorders. Health care workers have reported high rates of PTSD during the pandemic — a February study of 1,000 frontline workers reported that nearly one-quarter showed likely signs of the disorder. In contrast, only 6.8 percent of the general population ever experiences PTSD in their lifetime, according to National Institute of Mental Health estimates.
“Covid has been traumatizing to so many people in so many ways,” said Dr. Nomi Levy-Carrick, a psychiatrist who leads outpatient psychiatric services at Brigham and Women’s Hospital in Boston. Grief, isolation, economic upheaval, housing and food insecurity, the “toxic stress” of lockdown and the surge in domestic violence during the pandemic can all be traumatic stressors, she said. And the constant uncertainty of the past pandemic year created conditions for widespread anxiety.
Academics have studied virtual reality’s potential to treat anxiety disorders since the ’90s, and the practice has incrementally gathered momentum, as the technology has improved and headsets have become more affordable. JoAnn Difede, a psychology professor at Weill Cornell Medicine in New York and one of the leading experts in virtual reality treatment for PTSD, said the headset she used for research with Sept. 11 survivors cost $25,000 at the time and weighed 10 pounds. Now, an average headset retails under $300.
Recreational V.R. headset sales to the general public have grown during the pandemic, but the technology has yet to fully enter the mainstream. Experts who study the therapy argue that’s about to change for the medical establishment, as clinicians look for effective and accessible ways to treat anxiety disorders.
Mr. Merkle likened his experience in the virtual reality simulations to a child confronting imaginary monsters in a closet. Each time you open the door, he said, you see there’s nothing to fear. Your body whirs down from fight or flight mode. And each time, the virtual reality treatment gets easier.
Many V.R. therapies build on a sometimes-divisive therapeutic technique called prolonged exposure, developed by Edna Foa, a professor of psychiatry at the University of Pennsylvania Perelman School of Medicine. Prolonged exposure is a cognitive intervention therapy; patients first describe a traumatic event to a therapist, in detail and in the present tense, and then confront triggers of the traumatic event in the real world. While some experts have worried the practice might overwhelm or re-traumatize patients, prolonged exposure is now widely accepted as an effective tool to treat chronic PTSD. Patients become desensitized to their memories; they prove to themselves that their thoughts can be safe.
“If you overcome something in V.R., you overcome it in real life,” said Daniel Freeman, a professor of clinical psychiatry at Oxford University who runs virtual reality therapies at 10 public clinics across England.
Direct-to-consumer virtual reality therapy products, for now, remain rare, and only a few are covered by insurance. Companies that sell V.R. therapy software often explicitly state their products should only be used in the presence of a clinician. Experts like Andrew Sherrill, an assistant professor of psychiatry at Emory University in Atlanta who specializes in virtual reality therapy., worry that, as virtual reality expands, people seeking treatment might try out a program for themselves and not consult a therapist. They might shrug off the treatment after not getting results or aggravate trauma symptoms. “It’s the closest thing our field has to just making opioids available over the counter,” he said.
“V.R. is not going to be the solution,” said Jonathan Rogers, a researcher at University College London who has studied rates of anxiety disorders during the pandemic. “It may be part of the solution, but it’s not going to make medications and formal therapies obsolete.”
Does V.R. Therapy Work?
Virtual reality treatments aren’t necessarily more effective than traditional prolonged exposure therapy, said Dr. Sherrill. But for some patients, V.R. offers convenience and can immerse a patient in scenes that would be hard to replicate in real life. For some people, the treatment can mimic video game systems they’re already familiar with. There’s also a dual awareness in patients who use virtual reality — the images on the screen are almost lifelike, but the headset itself functions as proof that they’re not real.
Months after the Sept. 11 terrorist attacks, Dr. Difede and Dr. Hunter Hoffman, who is the director of the Virtual Reality Research Center at the University of Washington, tested virtual reality treatments in one survivor with acute PTSD, one of the first reported applications of the therapy. Dr. Difede said that the first time the patient put on the headset, she started crying. “I never thought I’d see the World Trade Center again,” she told Dr. Difede. After six hourlong sessions, the patient experienced a 90 percent decrease in PTSD symptoms. Dr. Difede later tested V.R. exposure therapy in Iraq War veterans; 16 out of the first 20 patients no longer met the diagnostic criteria for PTSD after completing treatment.
At the University of Central Florida, a team called U.C.F. Restores has been building trauma therapies using V.R. that allows clinicians to control the level of detail in a simulation, down to the color of a bedspread or a TV that can be clicked on or off, in order to more easily trigger traumatic memories. The program offers free trauma therapy, often using V.R., to Florida residents and focuses on treating PTSD.
Dr. Deborah Beidel, a professor of psychology and executive director of U.C.F. Restores, has broadened the treatments beyond visuals, customizing sounds and even smells to create an augmented reality for patients.
Jonathan Tissue, 35, a former Marine, sought treatment at U.C.F. Restores in early 2020 after talk therapy and medication failed to alleviate his PTSD symptoms, which included flashbacks, anxiety and mood swings. In the end, it was the smells pumped into the room while he described his military service to a clinician that helped unlock his memories. There was the stench of burning tires, diesel fumes, the smell of decaying bodies. He heard the sounds of munitions firing. His chair rumbled, thanks to the center’s simulated vibrations.
“It unlocked certain doors that I could start speaking about,” he said. He talked through his newly uncovered memories with a therapist and a support group, processing the terror that had built in his body for years.
Within three days, he said, he started feeling better; by the end of the three-week treatment, his symptoms had mostly faded. “It made me comfortable in my own self,” he said.
‘Ready for Prime Time’
While a significant amount of funding — and consequentially, the bulk of research — on virtual reality’s therapeutic potential has focused on military veterans, “we’re ready for prime time to treat civilian trauma,” said Albert “Skip” Rizzo, a clinical psychologist who specializes in virtual reality and worked with Mr. Merkle at the Department of Veterans Affairs.
Several companies and clinicians are using V.R. to treat other disorders. During the pandemic, Johns Hopkins researchers have used it to reduce stress and burnout in medical workers. In one unpublished study, 50 nurses from a Covid-19 ward tested virtual reality mindfulness exercises — guided meditations beside animated fields and waterfalls — and all but one participant reported reduced stress levels.
Researchers are also testing whether they can alleviate childhood social anxiety with virtual reality programs, one of which uses animated artificial intelligence bullies that growl things like, “Give me your lunch money.” BehaVR, which currently sells therapeutic software on pre-loaded headsets to health care providers, plans to expand to direct-to-consumer products for social anxiety and other stress-related disorders, anticipating widespread post-pandemic fears, Aaron Gani, the company’s founder and chief executive said in an interview.
Virtual reality looks promising for treating phobias, according to Dr. Howard Gurr, a psychologist in Long Island, N.Y. He’s been interested in virtual reality for more than 20 years, since he saw Dr. Rizzo discuss a virtual classroom environment to diagnose and treat childhood attention-deficit/hyperactivity disorder. But the technology has improved drastically in recent years, he said.
In 2016, Dr. Gurr tried a simulation to treat patients’ fear of heights that convinced him of V.R.’s therapeutic potential. A glass elevator steadily rose over a city, the roofs of the buildings below growing smaller and smaller. A balcony appeared, and he was supposed to take a step onto it, over the chasm. Even though he didn’t have a phobia of heights, Dr. Gurr couldn’t do it. “Part of my brain was hijacked,” he said. “I was like, ‘I got it. This works.’”
Before he found virtual reality, Dr. Gurr would accompany a patient with a phobia of flying on an actual flight — a short distance, like New York to Philadelphia, over and over again. Now, he said, it’s more efficient and convenient to talk them through a virtual plane ride five or six times in a given session, on and off a pixelated runway. About one-third of his patients now come to his psychology practice specifically for virtual reality, he said, referred from other clinicians who don’t offer the treatment.
That number may grow as the pandemic wanes in the United States, he said, and more people grapple with its aftermath. He expects anxiety disorders will continue to rise, that the demand for effective treatments to tackle fear and trauma will only expand. Mr. Merkle, who’s in the process of getting a degree in clinical psychology, mostly relies on traditional talk therapy these days. PTSD has no clear end point; even in recovery, it can trap you, cycling and churning. But for now, he said, thanks to the V.R. treatment, he feels something close to free.
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