The game goes like this: You are Spc. Kyle Norton, a 19-year-old Midwesterner whose life has begun to spiral downward following a bomb-disposal assignment in Iraq. Already beset by financial difficulties, you receive a surprise email from your fiancée, who announces that she has become pregnant by another man. Still reeling from this news, you learn that your best friend has just been killed in an ambush. As these scenarios unfold, questions appear on your videoscreen, prompting you to decide whether, as Norton, you should seek help for these issues. Depending on your responses, Norton either becomes more suicidal or begins to heal.
This game, Beyond the Front, is the brainchild of WILL Interactive, a Maryland-based company that gets 75 percent of its business from the military. WILL’s products are examples of what game aficionados and scholars call “serious games,” a phrase referring to any game whose main purpose is something other than entertainment. Though it may be entertaining, a serious game’s primary function is to educate the user or help her solve a problem. While they are used extensively in health care, engineering, and other fields, the primary maker and user of serious games has always been the military, which uses them in a number of ways including as training tools for combat and as a form of therapy for returning service members.
The games developed for the military are primarily non-combat-related, focusing instead on what WILL’s C.E.O., Sharon Sloane, calls “high-stress situations, high-risk situations, and emotional issues,” including suicide prevention, sexual assault, and reintegration into civilian life. Sloane says that WILL’s games have evolved with the military to match the issues that are “keeping the leadership up at night.” Ten years ago, she says, “we wouldn’t have done PTSD and suicide prevention. We wouldn’t have done training for warrior transition units or soldiers who are severely injured physically.” At the moment, with the war in Afghanistan winding down the leadership’s primary concern is, Sloane says, “what happens when soldiers return from their deployments. The strains and the stresses on the family members.”
One of the most promising therapeutic tools for treating veterans’ PTSD comes, perhaps surprisingly, in the form of a modified first-person shooter game. But the purpose of Virtual Iraq/Afghanistan could not be further from the commercial entertainment of its blockbuster brethren. Now operating at dozens of sites across the country, Virtual Iraq/Afghanistan—developed by Dr. Albert “Skip” Rizzo at the army-funded, USC-affiliated Institute for Creative Technologies in Los Angeles—is the most widely used “virtual reality exposure therapy” treatment program in America. The treatment is a variation on traditional exposure therapy, which itself derives from classical conditioning, in the manner of Pavlov and his dogs. The idea is that by reenacting a traumatic experience or confronting an irrational fear and then gradually increasing the intensity of the experience in the context of a safe, therapeutic environment, a patient will “habituate” to that experience or fear. The trauma will not disappear, but it will become manageable.
Virtual-reality exposure therapy is made possible by recent technical advances in computing speed, graphics rendering, artificial intelligence, and tracking and interface technology. Wearing a head-mounted display (a helmet with goggles and earphones), patients are placed in immersive, interactive environments designed to represent their traumatic memories. Since its origins in the early 1990s, virtual-reality exposure therapy has proved remarkably effective at treating anxiety disorders with initial studies indicating a “cure” rate of between 70 and 90 percent. The Department of Defense has been the largest funder of research, with Virtual Iraq/Afghanistan almost single-handedly responsible for bringing this form of therapy to the attention of the larger psychiatric community.
According to the Journal of CyberTherapy and Rehabilitation, over 15 studies entailing diverse populations have shown that virtual-reality exposure therapy (VRET) enhances traditional cognitive-behavioral-treatment regimens for PTSD. The journal reports that most studies reveal a treatment success rate of 66 to 90 percent. An issue of Studies in Health Technology and Informatics, meanwhile, summarized case studies from a Navy-funded project comparing the effects of VRET with the effects of traditional treatment on active-duty personnel. The results showed that VRET led to measurable reductions in reported symptoms of depression, anxiety, and PTSD.
Most recently, Military Medicine reported on a treatment-development project aimed at evolving and testing a method for applying VRET to active-duty service members diagnosed with PTSD. Forty-two service members were enrolled, 20 of them completed treatment. Of those 20, 75 percent had experienced at least a 50 percent reduction in PTSD symptoms and no longer met DSM-IV criteria for PTSD. On average, PSTD scores decreased by 50.4 percent, depression scores by 46.6 percent, and anxiety scores by 36 percent. Analyses showed that the significant improvements in PTSD, depression, and anxiety occurred over the course of treatment and were maintained at follow up.
In my new book, War Play: Video Games and the Future of Armed Conflict, I detail the military’s extensive use of videogames for training, education, and recruitment—a use that is being taken up by companies and schools nationwide. But if we ask what effects the military’s contribution to videogames will have on society at large, it is increasingly clear that one of the areas of greatest influence will be the field of mental health. In this sense, the most important videogame-related legacy of our wars in Afghanistan and Iraq may have nothing to do with preparing for war at all, but with treating war’s aftermath.