Virtual Reality Goes to War: A Brief Review of the Future of Military Behavioral Healthcare

  • Albert RizzoEmail author
  • Thomas D. Parsons
  • Belinda Lange
  • Patrick Kenny
  • John G. Buckwalter
  • Barbara Rothbaum
  • JoAnn Difede
  • John Frazier
  • Brad Newman
  • Josh Williams
  • Greg Reger


Numerous reports indicate that the incidence of posttraumatic stress disorder (PTSD) in returning OEF/OIF military personnel is creating a significant healthcare challenge. These findings have served to motivate research on how to better develop and disseminate evidence-based treatments for PTSD. Virtual Reality delivered exposure therapy for PTSD has been previously used with reports of positive outcomes. This article details how virtual reality applications are being designed and implemented across various points in the military deployment cycle to prevent, identify and treat combat-related PTSD in OIF/OEF Service Members and Veterans. The summarized projects in these areas have been developed at the University of Southern California Institute for Creative Technologies, a U.S. Army University Affiliated Research Center, and this paper will detail efforts to use virtual reality to deliver exposure therapy, assess PTSD and cognitive function and provide stress resilience training prior to deployment.


Virtual reality Exposure therapy PTSD Behavior therapy Veterans, service members Military Invisible wounds of war Stress resilience 



The projects described here have been sponsored by the Office of Naval Research, TATRC, MRMC, DCoE, and U.S. Army Research, Development, and Engineering Command (RDECOM). Statements and opinions expressed do not necessarily reflect the position or the policy of the United States Government, and no official endorsement should be inferred.


  1. ASVAB. (2010, December 14, 2010). History of military testing. Retrieved from
  2. Bartone, P. T. (2006). Resilience under military operational stress: Can leaders influence hardiness? Military Psychology, 18, S131–S148.CrossRefGoogle Scholar
  3. Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893–897.PubMedCrossRefGoogle Scholar
  4. Bilmes, L. (January 20, 2007). Soldiers returning from Iraq and Afghanistan: The long-term costs of providing veterans medical care and disability benefits. Faculty Research Working Paper Series. John F. Kennedy School of Government, Harvard University. Retrieved from
  5. Blake, D. D., Weathers, F., Nagy, L. M., Kaloupek, D., Klauminizer, G., Charney, D., et al. (1990). A clinician rating scale for assessing current and lifetime PTSD: The CAPS-1. Behavior Therapist, 13, 187–188.Google Scholar
  6. Blanchard, E. B., Jones-Alexander, J., Buckley, T. C., & Forneris, C. A. (1996). Psychometric properties of the PTSD checklist (PCL). Behaviour Research and Therapy, 34, 669–673.PubMedCrossRefGoogle Scholar
  7. Comprehensive Soldier Fitness Program. (December 1, 2010). Main page. Retrieved from
  8. Cornum, R. (July 10, 2010). Comprehensive soldier fitness. Retrieved from
  9. Department of Defense. (December 4, 2010a). Retrieved from
  10. Department of Defense. (December 4, 2010b). Retrieved from
  11. Difede, J., Cukor, J., Jayasinghe, N., Patt, I., Jedel, S., Spielman, L., et al. (2007). Virtual reality exposure therapy for the treatment of posttraumatic stress disorder following September 11, 2001. Journal of Clinical Psychiatry, 68, 1639–1647.PubMedCrossRefGoogle Scholar
  12. Difede, J., & Hoffman, H. G. (2002). Virtual reality exposure therapy for world trade center post-traumatic stress disorder: A case report. Cyberpsychology and Behavior, 5, 529–535.PubMedCrossRefGoogle Scholar
  13. Fischer, H. (December 4, 2010). United States military casualty statistics: Operation new dawn, operation Iraqi freedom, and operation enduring freedom. Congressional Research Service 7-5700:RS22452. Retrieved from
  14. Foa, E. B., Davidson, R. T., & Frances, A. (1999). Expert consensus guideline series: Treatment of posttraumatic stress disorder. American Journal of Clinical Psychiatry, 60, 5–76.CrossRefGoogle Scholar
  15. Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20–35.PubMedCrossRefGoogle Scholar
  16. Gerardi, M., Rothbaum, B. O., Ressler, K., Heekin, M., & Rizzo, A. A. (2008). Virtual reality exposure therapy using a virtual Iraq: Case report. Journal of Traumatic Stress, 21, 209–213.PubMedCrossRefGoogle Scholar
  17. Hays, R. T., Jacobs, J. W., Prince, C., & Salas, E. (1992). Requirements for future research in flight simulation training: Guidance based on a meta-analytic review. International Journal of Aviation Psychology, 2, 143–158.CrossRefGoogle Scholar
  18. Hoffman, H. G., Chambers, G. T., Meyer, W. J., Araceneaux, L. L., Russell, W. J., Seibel, E. J., et al. (2011). Virtual reality as an adjunctive non-pharmacologic analgesic for acute burn pain during medical procedures. Annals of Behavioral Medicine, 41(2), 183–191.PubMedCrossRefGoogle Scholar
  19. Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13–22.PubMedCrossRefGoogle Scholar
  20. Holden, M. K. (2005). Virtual environments for motor rehabilitation: Review. CyberPsychology and Behavior, 8, 187–211.CrossRefGoogle Scholar
  21. Hovar, C. (December 10, 2010). The military operational medicine research program for the US Army. Retrieved from
  22. Institute of Medicine Committee on Treatment of Posttraumatic Stress Disorder. (2007). Treatment of posttraumatic stress disorder: An assessment of the evidence. ISBN: 0-309-10925-6. Accessed on Aug 24, 2007, from
  23. Jaycox, L. H., Foa, E. B., & Morral, A. R. (1998). Influence of emotional engagement and habituation on exposure therapy for PTSD. Journal of Consulting and Clinical Psychology, 66, 186–192.CrossRefGoogle Scholar
  24. Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: A new depression and diagnostic severity measure. Psychiatric Annals, 32, 509–521.Google Scholar
  25. Luthar, S. S., Cicchetti, D., & Becker, B. (2000). The construct of resilience: A critical evaluation and guidelines for future work. Child Development, 71, 543–562.PubMedCrossRefGoogle Scholar
  26. McEwen, B. S., & Stellar, E. (1993). Stress and the individual: Mechanism leading to disease. Archives of Internal Medicine, 153, 2093–2101.PubMedCrossRefGoogle Scholar
  27. Merians, A. S., Fluet, G. G., Qiu, Q., Saleh, S., Lafond, I., & Adamovich, S. V. (2010). Integrated arm and hand training using adaptive robotics and virtual reality simulations. In Proceedings of the 2010 International Conference on Disability, Virtual Reality and Associated Technology (pp. 213–222) Maia, Portugal.Google Scholar
  28. ONR. (December 14, 2010). The Office of Naval Research human performance training and education thrust. Retrieved from
  29. Ortony, A., Clore, G. L., & Collins, A. (1988). The cognitive structure of emotions. Cambridge: Cambridge University Press.Google Scholar
  30. Parsons, T. D., Cosand, L., Courtney, C., Iyer, A., & Rizzo, A. A. (2009). Neurocognitive workload assessment using the virtual reality cognitive performance assessment test. Lecture Notes in Artificial Intelligence, 5639, 243–252.Google Scholar
  31. Parsons, T. D., & Courtney, C. (2010). Neurocognitive and psychophysiological interfaces for adaptive virtual environments. In C. T. Röcker & M. Ziefle (Eds.), Human centered design of e-health technologies. Hershey: IGI Global.Google Scholar
  32. Parsons, T. D., Courtney, C., Cosand, L., Iyer, A., Rizzo, A. A., & Oie, K. (2009). Assessment of psychophysiological differences of west point cadets and civilian controls immersed within a virtual environment. Lecture Notes in Artificial Intelligence, 5638, 514–523.Google Scholar
  33. Parsons, T. D., Iyer, A., Cosand, L., Courtney, C., & Rizzo, A. A. (2009). Neurocognitive and psychophysiological analysis of human performance within virtual reality environments. Studies in Health Technology and Informatics, 142, 247–252.PubMedGoogle Scholar
  34. Parsons, T. D., Pair, J., Brennan, J., Silva, T., & Rizzo, A. A. (2008). Sex differences in spatial cognition within a virtual environment: Virtual reality cognitive performance assessment test (VRCPAT). Journal of the International Neuropsychological Society, 14, 2.Google Scholar
  35. Parsons, T. D., & Rizzo, A. A. (2008a). Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: A meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry, 39, 250–261.PubMedCrossRefGoogle Scholar
  36. Parsons, T. D., & Rizzo, A. A. (2008b). Initial validation of a virtual environment for assessment of memory functioning: Virtual reality cognitive performance assessment test. Cyberpsychology and Behavior, 11, 17–25.PubMedCrossRefGoogle Scholar
  37. Parsons, T. D., & Rizzo, A. A. (2008c). Neuropsychological assessment of attentional processing using virtual reality. Annual Review of CyberTherapy and Telemedicine, 6, 23–28.Google Scholar
  38. Parsons, T. D., Rizzo, A. A., Rogers, S. A., & York, P. (2009). Virtual reality in pediatric rehabilitation: A review. Developmental Neurorehabilitation, 12, 224–238.PubMedCrossRefGoogle Scholar
  39. Powers, M., & Emmelkamp, P. M. G. (2008). Virtual reality exposure therapy for anxiety disorders: A meta-analysis. Journal of Anxiety Disorders, 22, 561–569.PubMedCrossRefGoogle Scholar
  40. Reger, G., & Gahm, G. (2008). Virtual reality exposure therapy for active duty soldiers. Journal of Clinical Psychology, 64, 940–946.PubMedCrossRefGoogle Scholar
  41. Reger, G. M., Gahm, G. A., Rizzo, A. A., Swanson, R. A., & Duma, S. (2009). Soldier evaluation of the virtual reality Iraq. Telemedicine and e-Health Journal, 15, 100–103.Google Scholar
  42. Reger, G. M., Holloway, K. M., Candy, C., Rothbaum, B. O., Difede, J., Rizzo, A. A. & Gahm, G. A. (2011). Effectiveness of virtual reality exposure therapy for active duty soldiers in a military mental health clinic. Journal of Traumatic Stress, 24(1), 93–96.PubMedCrossRefGoogle Scholar
  43. Reger, G. M., Parsons, T. D., Gahm, G. A., & Rizzo, A. A. (2010). Virtual reality assessment of cognitive functions: A promising tool to improve ecological validity. Brain Injury, 7, 24–26.Google Scholar
  44. Ressler, K. J., Rothbaum, B. O., Tannenbaum, L., Anderson, P., Zimand, E., Hodges, L., et al. (2004). Facilitation of psychotherapy with D-cycloserine, a putative cognitive enhancer. Archives of General Psychiatry, 61, 1136–1144.PubMedCrossRefGoogle Scholar
  45. Riva, G. (2005). Virtual reality in psychotherapy: Review. CyberPsychology and Behavior, 8, 220–230.PubMedCrossRefGoogle Scholar
  46. Rizzo, A. (2010). Virtual Iraq/Afghanistan and how it is helping some troops and vets with PTSD. Veterans Today.
  47. Rizzo, A. A., Buckwalter, J. G., & Neumann, U. (1997). Virtual reality and cognitive rehabilitation: A brief review of the future. Journal of Head Trauma Rehabilitation, 12, 1–15.CrossRefGoogle Scholar
  48. Rizzo, A., Difede, J., Rothbaum, B. O., & Reger, G. (2010). Virtual Iraq/Afghanistan: Development and early evaluation of a virtual reality exposure therapy system for combat-related PTSD. Annals of the New York Academy of Sciences (NYAS), 1208, 114–125.CrossRefGoogle Scholar
  49. Rizzo, A. A., Klimchuk, D., Mitura, R., Bowerly, T., Buckwalter, J. G., & Parsons, T. (2006). A virtual reality scenario for all seasons: The virtual classroom. CNS Spectrums, 11, 35–44.PubMedGoogle Scholar
  50. Rizzo, A., Lange, B., Buckwalter, J. G., Forbell, E., Kim, J., Williams, J., et al. (2010). SimCoach: An intelligent virtual human system for providing healthcare information and support. In Proceedings of the 2010 International Conference on Disability, Virtual Reality and Associated Technology (pp. 213–222).Google Scholar
  51. Rizzo, A. A., Parsons, T., Buckwalter, J. G., & Kenny, P. (2011). The birth of intelligent virtual patients in clinical training. American Behavioral Scientist.Google Scholar
  52. Rizzo, A. A., Reger, G., Gahm G., Difede, J., & Rothbaum, B. O. (2009). Virtual reality exposure therapy for combat related PTSD. In P. Shiromani, T. Keane, & J. LeDoux (Eds.), Post-traumatic stress disorder: Basic science and clinical practice (pp. 375–399). New York: Humana Press.Google Scholar
  53. Rizzo, A. A., Schultheis, M. T., Kerns, K., & Mateer, C. (2004). Analysis of assets for virtual reality applications in Neuropsychology. Neuropsychological Rehabilitation, 14, 207–239.CrossRefGoogle Scholar
  54. Rose, F. D., Brooks, B. M., & Rizzo, A. A. (2005). Virtual reality in brain damage rehabilitation: Review. CyberPsych and Behavior, 8, 241–262.CrossRefGoogle Scholar
  55. Rothbaum, B. O., & Hodges, L. F. (1999). The use of virtual reality exposure in the treatment of anxiety disorders. Behavior Modification, 23, 507–525.PubMedCrossRefGoogle Scholar
  56. Rothbaum, B. O., Hodges, L., Ready, D., Graap, K., & Alarcon, R. (2001). Virtual reality exposure therapy for Vietnam veterans with posttraumatic stress disorder. Journal of Clinical Psychiatry, 62, 617–622.PubMedCrossRefGoogle Scholar
  57. Rothbaum, B. O., Meadows, E. A., Resick, P., & Foy, D. W. (2000). Cognitive-behavioral therapy. In E. B. Foa, M. Keane, & M. J. Friedman (Eds.), Effective treatments for PTSD (pp. 60–83). New York: Guilford.Google Scholar
  58. Rothbaum, B. O., Rizzo, A., & Difede, J. (2010). Virtual reality exposure therapy for combat-related posttraumatic stress disorder. Annals of the New York Academy of Sciences (NYAS), 1208, 126–132.CrossRefGoogle Scholar
  59. Rothbaum, B. O., & Schwartz, A. (2002). Exposure therapy for posttraumatic stress disorder. American Journal of Psychotherapy, 56, 59–75.PubMedGoogle Scholar
  60. Roy, M. J., Francis, J., Friedlander, J., Banks-Williams, L., Lande, R. G., Taylor, P., et al. (2010). Improvement in cerebral function with treatment of posttraumatic stress disorder. Annals of the New York Academy of Sciences (NYAS), 1208, 142–149.CrossRefGoogle Scholar
  61. Schneider, S. M., Kisby, C. K. & Flint, E. P. (December 10, 2010). Effect of virtual reality on time perception in patients receiving chemotherapy. Supportive Care in Cancer, Retrieved from
  62. Seal, K. H., Bertenthal, D., Nuber, C. R., Sen, S., & Marmar, C. (2007). Bringing the war back home: Mental health disorders among 103, 788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine, 167, 476–482.PubMedCrossRefGoogle Scholar
  63. Singer, B., & Ryff, C. D. (2001). Understanding aging via person-centered methods and the integration of numbers and narratives. In R. H. Binstock & L. K. George (Eds.), Handbook of aging, the social sciences (5th ed.). San Diego: Academic Press.Google Scholar
  64. Stanton, D., Foreman, N., & Wilson, P. (1998). Uses of virtual reality in clinical training: Developing the spatial skills of children with mobility impairments. In G. Riva, B. Wiederhold, & E. Molinari (Eds.), Virtual reality in clinical psychology and neuroscience (pp. 219–232). Amsterdam: IOS Press.Google Scholar
  65. Tanielian, T., Jaycox, L. H., Schell, T. L., Marshall, G. N., Burnam, M. A., Eibner, C., et al. (2008). Invisible wounds of war: Summary and recommendations for addressing psychological and cognitive iInjuries. Rand Report. Retrieved from
  66. U.S. Army Training and Doctrine Command. (December 2, 2010). The U.S army study of the human dimension in the future 2015–2024 (Pam 525-3-7-01). Retrieved from
  67. Walker, D. L., Ressler, K. J., Lu, K. T., & Davis, M. (2002). Facilitation of conditioned fear extinction by systemic administration or intra-amygdala infusions of D-cycloserine as assessed with fear-potentiated startle in rats. Journal of Neuroscience, 22, 2343–2351.PubMedGoogle Scholar
  68. Wilson, J., Onorati, K., Mishkind, M., Reger, M., & Gahm, G. A. (2008). Soldier attitudes about technology-based approaches to mental healthcare. Cyberpsychology and Behavior, 11, 767–769.PubMedCrossRefGoogle Scholar
  69. Wu, D., Courtney, C., Lance, B., Narayanan, S. S., Dawson, M., Oie, K., et al. (2010). Optimal arousal identification and classification for affective computing: Virtual Reality Stroop Task. IEEE Transactions on Affective Computing, 99, 1–10.Google Scholar
  70. Zimand, E., Anderson, P., Gershon, G., Graap, K., Hodges, L., & Rothbaum, B. (2003). Virtual reality therapy: Innovative treatment for anxiety disorders. Primary Psychiatry, 9, 51–54.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Albert Rizzo
    • 1
    Email author
  • Thomas D. Parsons
    • 1
  • Belinda Lange
    • 1
  • Patrick Kenny
    • 1
  • John G. Buckwalter
    • 1
  • Barbara Rothbaum
    • 2
  • JoAnn Difede
    • 3
  • John Frazier
    • 1
  • Brad Newman
    • 1
  • Josh Williams
    • 1
  • Greg Reger
    • 4
  1. 1.Institute for Creative TechnologiesUniversity of Southern CaliforniaPlaya VistaUSA
  2. 2.Department of PsychiatryEmory UniversityAtlantaUSA
  3. 3.Department of PsychiatryWeill Cornell Medical CollegeNew YorkUSA
  4. 4.National Center for Telehealth and Technology, Joint Base Lewis-McChordTacomaUSA

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