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References

Nelson, R. J. (2013). Is virtual reality exposure therapy effective for service members and veterans experiencing

combat-related PTSD? Traumatology, 19(3), 171–178. https://doi-org.library.capella.edu/10.1177

/1534765612459891

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Is Virtual Reality Exposure Therapy Effective for Service Members and Veterans Experiencing

Combat-Related PTSD? / Article

By: Rebekah J. Nelson;

Florida State University, Tallahassee, FL, USA

Acknowledgement: The author thanks Dr Bruce Thyer for his assistance in preparing this manuscript for

publication.

The author declared no potential conflicts of interest with respect to the research, authorship, and/or

publication of this article.

The author received no financial support for the research, authorship, and/or publication of this article.

Concern over the best methods to prevent and treat combat-related posttraumatic stress disorder (PTSD) in

military service members and military veterans has been of particular interest with the resurgence of military

service members who are serving multiple tours in Iraq and Afghanistan. Preventative programs such as

comprehensive soldier fitness (Casey, 2011) acknowledge the need for the military services to have a more

frank discussion with their service members about PTSD. The stigma within the military of a PTSD diagnosis

prevents many service members from seeking treatment, even when they recognize the symptoms of PTSD

in themselves. While military programs, such as the Department of Veterans Affairs, have sought to educate

service members and their families about the importance of seeking treatment for PTSD, the threat of having

a diagnosis of PTSD on their service record stops many service members from seeking help. Some have

been able to seek treatment outside of the military health care system, but such treatment can be costly.

Another related population is military veterans who, like their present-day counterparts, did not seek treatment

or for whom no appropriate treatment was available.

The preferred treatment for anxiety disorders is exposure therapy (Powers & Emmelkamp, 2008), also known

as prolonged or gradual exposure therapy. Exposure therapy is a type of behavior therapy where the client is

taught cognitive and behavioral techniques such as progressive muscle relaxation, breathing exercises,

recognition of automatic thoughts and schemas, and cognitive restructuring (Pull, 2005). The client is taught

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to utilize these interventions while the therapist gradually exposes the client to the cause of anxiety,

increasing the intensity of exposure as the client is able to tolerate in order to help the client become more

accustomed to the stimuli-evoking anxiety. Clients also undertake self-conducted exposure-based exercises

as homework in between formal treatment sessions. Two types of exposure therapy have dominated the field:

in vivo therapy, where the therapist and client are able to experience exposure to anxiety-evoking stimuli in

increasingly naturalistic settings; and imaginal exposure therapy, where the therapist leads the client in

imagining the cause of anxiety. Usually exposure therapy (ET) in imagination is followed by real-life exposure.

These two types of exposure therapy are sometimes poorly tolerated by service members and veterans who

have combat-related PTSD because of the distinctness of the settings in which the trauma occurred, and

because of the tendency of clients to suppress thoughts that activate PTSD symptoms (Riva et al., 2010).

A relatively new exposure-based treatment for PTSD that has gained attention in the media and the

therapeutic community is the use of virtual reality programs. Using virtual reality in place of real-life or

imaginal exposure therapy allows clients to receive and process exposure to traumatic events in a relatively

safe environment. Virtual reality exposure therapy (VRET) has been tested with persons experiencing PTSD

symptoms in multiple trials and with many different causes of anxiety (Gerardi, Cukor, Difede, Rizzo, &

Rothbaum, 2010; Pull, 2005). In their meta-analysis on the use of VRET for anxiety disorders, Powers and

Emmelkamp (2008) found VRET to have a slightly more powerful effect than did real-life exposure treatment.

This review will assess studies of the effectiveness of VRET when used to treat service members and military

veterans diagnosed with combat-related PTSD. It will also consider the practical use of the technology,

including the cost of treatment and the possible application of VRET in the assessment and prevention of

PTSD in active duty soldiers.

PTSD is a type of anxiety disorder brought on by experiencing or witnessing a traumatic event or events.

Traumatic events are defined by the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.;

DSM-IV-TR; American Psychiatric Association, 2000) as events “that involved actual or threatened death or

serious injury, or a threat to the physical integrity of self or others” (p. 467). The response to the trauma also

yields feelings of hopelessness, fear, or horror. The traumatic event must be reexperienced in some way,

such as through nightmares or physical reactions to events resembling the trauma. There must also be an

avoidance of stimuli that cause thoughts about the trauma and increased arousal, such as hypervigilance.

These symptoms must have lasted for more than 1 month, and must be causing clinically significant distress

for the individual.

Therapists using VRET to treat PTSD seek to simulate a virtual world that is as similar as possible to the real-

world environment in which the traumatic event occurred. This is referred to as a “sense of presence” in the

virtual world, or the level to which clients actually feel the virtual environment mirrors reality. In a qualitative

study of clinician perceptions about VRET (Kramer et al., 2010), clinicians expressed concern that the virtual

environment would not be realistic enough in order to trigger and then reduce anxiety. However, in their

evaluation study of the realism of two virtual Iraq scenarios, Reger, Gahm, Rizzo, Swanson, and Duma (2009)

conducted a convenience sample study with 93 soldiers not diagnosed with PTSD to see if the soldiers, who

had been deployed to Iraq one or more times, felt this sense of presence. A majority of the soldiers rated the

convoy scenario (86%) and the city environment (82%) from adequate to excellent.

VRET uses several technology-based methods to engage all five senses of the client, making the exposure

feel as realistic as possible. The technology used generally includes a “controlled delivery of sensory

stimulation via the therapist, including visual, auditory, olfactory, and tactile cues” (Gerardi et al., 2010, p.

299). Visual effects include being able to change the time of day, weather, number of pedestrians and

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vehicles, street debris, Humvees, planes, and helicopters clients see within the virtual world. Most of the

machines include an orientation tracker, which allows clients to move about the virtual environment via

headgear that responds to the movements of the participant. Olfactory senses are also engaged using scent

palettes, which blow smells such as spices or burning rubber, and are controlled by the therapist. The

therapist can also include sounds such as sirens, people crying, gunshots and mortars, helicopters,

improvised explosive devices, rocket-propelled grenades, car bombs, and sounds of an insurgent attack. In

their narrative review of the many uses of VRET, Gerardi et al. (2010) describe two scenarios available in their

virtual Iraq:

The city incorporates scenes such as marketplaces, security checkpoints, mosques, apartment buildings that

can be entered, and rooftops that can be accessed. The Humvee scenario includes a desert setting with

overpasses, checkpoints, debris, broken-down structures, and ambushes that can be introduced. (p. 303)

Finally, clients' seats are manipulated to create tactile vibrations in order to mimic a car ride, helicopter ride, or

an explosion. An example of the equipment and virtual reality scenarios utilized in VRET can be seen in many

media reports on the subject, such as a news report conducted by the Canadian Broadcasting Corporation on

the costs and benefits of VRET (Virtual Iraq Afghanistan Media Story CBC, video file).

Similar virtual settings can be created for veterans of wars in other areas of the world. Specific to this article

are virtual environments that mimic settings in Vietnam for veterans of the Vietnam War, and in Africa, where

a war was fought by Portuguese soldiers in Africa between 1963 and 1970.

As explained in Rothbaum, Hodges, Ready, Graap, and Alarcon's (2001) article on the use of VRET with

Vietnam veterans, VRET treatment spans several weeks of therapy, generally meeting twice a week for 90 to

120 min each session. The first session of VRET treatment is spent in assessing clients and gathering

information about the traumatic event they experienced. Sessions 2 and 3 are spent in acclimatizing clients to

the virtual reality equipment and environment, and in teaching clients cognitive behavioral interventions to

practice when their symptoms increase, such as breathing and relaxation techniques. Further therapy

sessions are spent in using the virtual environment to expose clients to traumatic memories while they

describe the events in detail. Homework assigned to clients generally includes listening to recordings of the

therapy sessions while practicing cognitive behavioral interventions learned in therapy.

Some who have been working on virtual reality technology have anticipated the use of it as an assessment

tool to determine whether a soldier is emotionally and mentally fit to return for another tour (McLay et al.,

2012). Others (Kraft, Amick, Barth, French, & Lew, 2010) also anticipate the use of virtual reality in

reassessing the driving ability of combat service members returning from Iraq or Afghanistan who have been

diagnosed with PTSD or traumatic brain injury (TBI), as these two disorders may critically affect returning

soldiers' ability to drive. In these ways, virtual reality technology may benefit soldiers as an assessment tool,

rather than solely a treatment for PTSD.

VRET has also been looked at as a prevention tool. Stetz, Long, Wiederhold, and Turner (2008) conducted a

study in which virtual reality and stress inoculation training were used to try and prevent medics who would be

serving in Iraq or Afghanistan from later developing PTSD. Stress inoculation training consists of exposing the

participant through virtual reality technology to traumatic events they may encounter in their future service in

hopes that when they encounter similar traumatic events in reality they will be able to use their practiced

cognitive behavioral skills to lessen their chances of developing PTSD in the future. While no distal measures

of whether the stress inoculation training provided in Stetz et al. (2008) are given, posttests suggest exposing

military medics preemptively to stressful situations may harden them against trauma. Such a preventative

effort may be useful to all military personnel, as Reger et al. (2009) report that 67% of a convenience sample

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(n = 93) of military service members had provided aid to persons who were wounded during their combat

experience. Exposure to such secondary trauma can sometimes serve as the initiating event triggering the

onset of PTSD; however, if service members were given preventative virtual reality stress inoculation training,

their chances of developing PTSD due to this exposure may decrease.

One of the concerns of implementing virtual reality therapy on a wide-scale basis is the approximate cost of

purchasing and setting up the virtual reality equipment and in training therapists to use the equipment

effectively. In their preliminary results utilizing virtual reality technology with active duty soldiers with PTSD,

Rizzo, Reger, Gahm, Difede, and Rothbaum (2009) approximate some of the costs of setting up an adequate

amount of virtual reality equipment in order to make the virtual environment realistic enough to help effect

change. However, the authors only provide actual dollar amounts regarding the Head Mounted Display

(US$1500) and the Logitech control pad (US$120) that creates vibrations in the seat of the participant. Table

1 is a list Rizzo et al. (2009) give of equipment needed to set up a virtual reality therapy environment. In an

interview with CBC news, Rizzo (Virtual Iraq Afghanistan Media Story CBC, video file) estimates the total cost

of virtual reality hardware to be approximately US$15,000, stating that the computer software for conducting

VRET can be obtained through him at no cost.

VRET Equipment Needed to Set Up a VRET Environment.

Wood et al. (2009) articulate the possible financial benefits implementing virtual reality technology could have

if the military were saved the money of having to replace service members who would have left the military

due to PTSD symptoms. They estimated that the training cost savings for the 12 participants in their study

would be just under US$330,000, whereas the training cost savings of treating PTSD with treatment as usual

would be close to US$193,000.

Pull (2005), Riva et al. (2010), and Gerardi et al. (2010) state that VRET may be more cost effective than

imaginal or real-life exposure therapy because it can be less time-consuming. This may be because the

technological equipment allows the clinician to have greater control over the magnitude of exposure in a

virtual environment than they would have in trying to help the client imagine graded images of the trauma or

feared object, thus taking less time overall to treat clients. Using virtual technology may also be less costly

than trying to have a real-life experience with the client. For example, Gerardi et al. (2010) cites the cost to

the patient of having a virtual experience with flying versus the cost of paying for a genuine flight.

Method

Search Strategy

Academic Search Complete, JSTOR, Applied Social Sciences Index and Abstracts (ASSIA), Computer and

Information Systems Abstracts, ERIC, ProQuest Dissertations, and Theses (PQDT), PsycINFO, Social

Services Abstracts, Sociological Abstracts, Social Sciences Citation Index, Web of Knowledge, Web of

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Science, Military and Government Collection, and Dissertation Abstracts were searched in order to find

studies pertaining to the topic. While the gray literature was not specifically searched, efforts were made to

obtain copies of articles and conference proceedings that were a result of the search strategy. Where

possible, search terms were limited to abstracts. The search terms used for this review were virtual and realit*

and (military or veteran*) and (PTSD or posttraumatic or post-traumatic). A flow chart (Figure 1) depicts the

disposition of retrieved articles.

Figure 1. Search strategy results for VRET treatment for military service members and veterans with PTSD.

Data Collection and Analysis Methods

While multiple case studies were found on this topic, only experimental and quasi-experimental studies

looking at the use of VRET as a treatment for military service members or veterans experiencing combat-

related PTSD will be included. The literature search yielded 100 studies. Seventy-one were ineligible based

on review of the title (including repeats of previously acquired studies), and a further 16 were excluded after

reviewing abstracts. Following a full-text review, seven more studies were excluded because they were found

to be preliminary results of studies already acquired, the text or pertinent information was unavailable, or the

study was analyzed in more than one of the resulting studies and the article with the most information was

chosen, leaving a total of six studies to include in the review (Table 2).

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VRET Reviewed Studies.

Common Measures Used to Assess PTSD in Military Service Members

The first, most common measure used in studying the effectiveness of treatment for PTSD is the Clinician

Administered PTSD Scale (CAPS; Gamito et al., 2010; McLay et al., 2011; Ready, Gerardi, Backsheider,

Mascaro, & Rothbaum, 2010; Ready, Pollack, Rothbaum, & Alarcon, 2006). The CAPS is a measure that

assesses the frequency and intensity of PTSD symptoms. Another measure commonly used with military

service members is self-report PTSD Checklist, Military Version (PCL-M; McLay et al., 2012; Reger et al.,

2011). The Impact of Events Scale Revised (IES-R; Gamito et al., 2010) is a self-report instrument that

measures PTSD symptoms of avoidance, intrusion, and hyperarousal, and the Symptoms Checklist Revised

(SCL-90-R; Gamito et al., 2010) is used to measure psychopathology. Finally, the Patient Health

Questionnaire-9 (PHQ-9; McLay et al., 2011) and the Beck Depression Inventory (BDI; Gamito et al., 2010;

Ready et al., 2006) are used to measure depression levels in clients, while the Beck Anxiety Inventory (BAI;

McLay et al., 2012) is used to measure anxiety levels in participants.

Therapists also use what are called Subjective Units of Discomfort/Distress Scale (SUDS) when using VRET.

SUDS are generally not tracked or measured for experimental purposes, but are used to understand how the

client is responding in the moment to the level of exposure in the virtual reality environment, and to decide if

the level of exposure should be increased or decreased based on participant reactivity. Physiological

monitoring through biofeedback is also often used to monitor client response to the virtual environment and, in

one study in this review (Wood et al., 2008) was used to measure the effectiveness of VRET.

Results

VRET With Active Duty Service Members

In their randomized controlled trial of VRET with active duty soldiers, McLay et al. (2011) used a convenience

sample to locate potential patients. They assigned 20 service members to VRET (n = 10) or to treatment as

usual (n = 10, with one participant not completing postassessment tests) using random assignment, and used

the CAPS as their outcome measure. While the VRET intervention appeared to follow the standard VRET

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treatment protocol, the treatment as usual group was not assigned to any particular treatment. Rather, they

were assigned to receive one or more of the treatments available for PTSD provided by the two hospital

locations, which included prolonged exposure (PE) therapy, EMDR, group therapy, psychiatric medication

management, substance rehab, and inpatient services. Unfortunately, only the number of mental health visits,

and not what type of treatment the TAU patients were receiving, was tracked. The findings for this study may

not, therefore, truly reflect the comparison between a VRET group and a TAU group, as we are unsure what

type of treatment the TAU group specifically received. Also, the TAU group was, at some point, changed to a

waiting-list group. It is unclear at what point this information was given to TAU group members, which may

have affected their confidence in the TAU treatment they received. McLay et al. (2011) found seven out of ten

of the VRET patients improved at least 30% on their CAPS scores from pretest to posttest. There was no

significant difference between CAPS scores after treatment; however, the authors found a significant

difference (p < .05) in the change from pretest to posttest mean scores between the VRET group (M = 35.4,

SD = 24.7) and the TAU (M = 9.4, SD = 26.6) group, favoring VRET.

Reger et al. (2011) conducted a convenience sample study with 24 active duty soldiers diagnosed with PTSD

(n = 18) or anxiety NOS (n = 6) who had been deployed at least once to Iraq or Afghanistan. The service

members had either requested to receive VRET as a treatment or had received previous treatment for their

disorder that was unsuccessful. The VRET was based on a training manual for the conduct of PE, delivered

by a clinical psychologist with formal training in both VRET and PE. Patients received treatment a mean of

27.8 months (SD = 17.3) after the trauma, and received an average of 7.4 (SD = 3.3) treatment sessions.

Researchers used the self-report PCL-M to measure treatment outcomes, and found patients reported a

significant (p = .001) improvement in PTSD symptoms from pretest (M = 60.92, SD = 11.03) to posttest (M =

47.08, SD = 12.7), with a large effect size (Cohen's d = 1.17).

A quasi-experimental convenience sample study of 20 active duty service members (McLay et al., 2012) used

the PCL-M, PHQ-9, and BAI to measure PTSD symptoms, depression, and anxiety. Their study revealed a

large effect size (Cohen's d = 1.34) between baseline PCL-M scores (n = 20, M = 53.8, SD = 9.6) and

posttreatment (M = 35.6, SD = 17.4) scores. For n = 17 participants, scores on the PCL-M also showed a

large effect size (Cohen's d = 2.17) between baseline (M = 53.8, SD = 9.6) and 3-month follow up (M = 28.9,

SD = 13.0). PHQ-9 scores at baseline (n = 20, M = 13.3, SD = 5.4) and posttreatment (M = 7.1, SD = 6.7)

were statistically significant (p < .002), as was the difference between baseline (n = 17, M = 12.9, SD = 5.4)

and 3-month follow up (M = 5.7, SD = 6.1, p < .001). Scores on the BAI showed a medium effect size

(Cohen's d = 0.56) between baseline (n = 20, M = 18.1, SD = 10.6) and posttreatment (M = 8.12, SD = 9.0),

and a large effect size (Cohen's d = 1.01) between baseline (n = 17, M = 18.1, SD = 10.6) and 3-month follow

up (M = 8.12, SD = 9.0). One limitation of this study was the large dropout rate between the intent to treat

group (n = 42) and the participants who completed treatment (n = 20).

VRET With Veterans

In their study comparing VRET with present-centered therapy (PCT), Ready et al. (2010) recruited clients

currently in treatment at the Atlanta VA Medical Center's Mental Health Clinic (n = 11, VRET n = 6, PCT n =

5), with one participant from each group dropping out. The clinician who interviewed participants was a

licensed clinical psychologist with several years of experience working with this population and was blind to

participant assignment. Clinicians used the Structured Clinical Interview for DSM-IV, the CAPS, and the Beck

Depression Inventory as measures. PCT as the comparison group included psychoeducation about PTSD,

problem-solving techniques, and a focus on the “here and now” problems clients experience. Both the VRET

and PCT groups experienced improvement in symptoms; however, the authors report “there was not

statistically significant improvement in CAPS or BDI scores when individual treatment conditions were

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isolated” (Ready et al., 2010, p. 52). The authors state that the small sample size impeded significant

differences between groups from being found. The VRET group seemed to have lower baseline CAPS scores

(M = 87.83, SD = 15.43) than the PCT group (M = 101.00, SD = 9.51). This is likely an artifact of the random

assignment procedure used with a small sample. The authors calculated effect sizes for the mean change in

the CAPS and BDI scores for each group. The mean change in CAPS scores for the VRET treatment group

yielded a small Cohen's d of 0.28 from pretest to posttest (n = 5, M = 31.8, SD = 39.1) and a medium Cohen's

d of 0.56 from pretest to follow up (n = 5, M = 25.0, SD = 28.1). Differences in the mean improvement of BDI

scores did not yield significant results. It is unclear why the authors chose to combine the treatment groups

and use a dependent samples t test to compare changes in CAPS scores on the entire sample between

baseline, post-treatment, and follow up. An independent samples t test of the same data for the VRET group

at baseline (n = 5, M = 101.0, SD = 9.51), posttreatment (n = 4, M = 75.5, SD = 22.22), and follow up (n = 5,

M = 87.00, SD = 6.32), compared to the PCT group at baseline (n = 6, M = 87.83, SD = 15.43), posttreatment

(n = 5, M = 59.2, SD = 32.24), and follow up (n = 4, M = 64.75, SD = 34.08) did not reveal any statistically

significant differences.

Gamito et al. (2010) completed a randomized controlled pilot study comparing VRET (n = 5), imaginal

exposure (n = 2), and waiting list control (n = 3) groups with Portuguese war veterans (n = 10) who had fought

in Africa between 1963 and 1970. Measures used to assess participants of the VRET group included the

CAPS, a structured interview from the DSM-IV, the IES-R, the SCL-90-R, and the BDI. It is unclear why, but

the SCL-90-R and BDI were not administered to the imaginal exposure and waiting list groups at baseline or

posttreatment. The authors report that BDI scores for the VRET group were significantly lower at

posttreatment. There were no statistically significant differences between groups at posttreatment on the

CAPS. The IES-R scores for the VRET group were reduced, whereas these scores for the imaginal group and

the waiting list control group increased, however the differences were not statistically significant. Due to the

small sample size, this study was statistically underpowered and therefore inadequate to validly compare

VRET with imaginal therapy and waiting list groups.

Ready et al. (2006) describe a group of multiple case studies (Rothbaum, 2006; Rothbaum et al., 2001)

where Vietnam veterans (n = 14) were treated with VRET. Mean CAPS scores at posttreatment (n = 14, M =

59.64, SD = 17.77), 3-month follow-up (n = 8, M = 55.13, SD = 14.38), and at 6-month follow-up (n = 11, M =

50.91, SD = 17.24) were all statistically significantly different (p < .05) than CAPS scores at baseline (n = 14,

M = 72.57, SD = 16.18). Scores on the BDI at posttreatment (n = 14, M = 21.14, SD = 8.18) and at the

6-month follow up (n = 11, M = 18.45, SD = 9.49) were statistically significantly different (p < .05) than at

baseline (n = 14, M = 24.86, SD = 9.70). Three-month posttreatment BDI scores (n = 8, M = 24.25, SD =

9.53), however, were not statistically significantly different from baseline BDI scores.

Discussion

Studies using VRET report several difficulties. First, the nature of the treatment itself appears to be difficult for

veterans to either comprehend or trust. It is suspected that the current generation of service members may be

reacting more positively to using virtual reality as a method of treating PTSD because they were raised in a

generation more familiar with this type of technology. Ready et al. (2010) describe the older veteran

population as being tentative about trusting the technology to actually help with their PTSD symptoms.

Another difficulty in using VRET with a veteran population is the amount of time that has lapsed between the

traumatic events and the treatment. Authors suspect the larger time lapse, in which participants have worked

harder for a longer period of time to suppress their PTSD symptoms, causes participants to have a more

difficult time in allowing themselves to relive the traumatic event in the virtual environment. As a reliving of the

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events multiple times is necessary in exposure therapy, this population has a much more difficult time in

succeeding with exposure therapy in general. Though the clinicians explain to participants and their families

that an increase in symptoms is likely to occur at the beginning of treatment, veterans seem to see this

increase in symptoms as evidence that the treatment is worsening their condition and may cause many to

terminate treatment. A qualitative study of clinician perceptions of VRET found clinicians not trained in the use

of VRET expressed concerns about the safety of using VRET with veterans, questioning whether the virtual

environment would exacerbate the symptoms of veterans (Kramer et al., 2010). However, in their meta-

analysis on the use of VRET with anxiety disorders, Powers and Emmelkamp (2008) conducted a meta-

regression analysis which showed that an increase in the number of virtual reality treatment sessions yielded

larger effects sizes. This difficulty in recruiting veterans as participants in trials using VRET has perhaps

stunted possible improvements that could be made to treatment protocols that would benefit veterans. Case

studies determining how VRET can be better tailored specifically to acclimatizing the veteran population to

exposure therapy and to virtual reality technology may be necessary. There have also been high dropout

rates in studies where participants are active duty service members (McLay et al., 2012), which could be

attributed to difficulties in balancing treatment with military duties, the time commitment of treatment sessions

(90-120 min twice weekly for 8-12 weeks), and the possibility of transfers to other military bases occurring

mid-treatment.

Kramer et al. (2010) also note that the use of virtual reality technology as a form of treatment may cause the

therapeutic alliance to suffer as a result. Therapists expressed concern that multitasking conducting therapy

and controlling complex computer software would prevent the development of an effective therapeutic

relationship. Measurement of how VRET can either positively or negatively affect the therapeutic alliance may

be useful in understanding how using a virtual environment can affect the usefulness of the relationship

between therapist and client.

Overall, the studies in this review found VRET to be beneficial to both active duty service members and

veterans experiencing combat-related PTSD. Each group has a different set of difficulties preventing them

from seeking or receiving treatment, which is evidenced by high levels of attrition. It may also explain the

difficulty in setting up experimental trials to test the efficacy of this treatment. Because the use of virtual reality

technology is such a specific field, and because the purchase and training of virtual reality equipment

expends both financial and time resources, the use of VRET in order to treat military service members and

veterans for PTSD is not likely to spread quickly. While the actual cost of virtual reality technology is

becoming less expensive, hesitation in the field over using exposure therapy in general, despite its positive

results, will likely continue to hinder this form of treatment.

One last area where future studies using VRET may want to focus is the distal impact VRET may have.

Treatment providers want to ensure positive treatment results continue over time. It has been suggested that

studies follow veterans and service members who have been treated with VRET for up to 2 years in order to

measure the distal effects of the treatment (Powers & Emmelkamp, 2008). If positive distal effects of the

treatment can be more readily established, the benefits of the treatment would perhaps balance out the

difficulties seen in implementing it on a wide-scale basis.

References

References marked with an asterisk indicate studies included in the systematic review. The in-text citations to

studies selected for systematic review are not preceded by asterisks.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text

revision). Arlington, VA: American Psychiatric Association.

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Casey, G. W. (2011). Comprehensive soldier fitness: A vision for psychological resilience in the U.S. Army.

American Psychologist, 66, 1–3.

*Gamito, P., Oliveira, J., Rosa, P., Morais, D., Duarte, N., Oliveira, S., & Saraiva, T. (2010). PTSD elderly war

veterans: A clinical controlled pilot study. Cyberpsychology, Behavior, and Social Networking, 13(1), 43–48.

Gerardi, M., Cukor, J., Difede, J., Rizzo, A., & Rothbaum, B. O. (2010). Virtual reality exposure therapy for

posttraumatic stress disorder and other anxiety disorders. Current Psychiatry Reports, 12, 298–305.

Kraft, M., Amick, M. M., Barth, J. T., French, L. M., & Lew, H. L. (2010). A review of driving simulator

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Source: Traumatology. Vol. 19. (3), Sep, 2013 pp. 171-178)

Accession Number: 2013-29758-001

Digital Object Identifier: 10.1177/1534765612459891

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