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In Defence of Virtual Reality Exposure Therapy

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Canadian_Vet:
The following is the full-text of a document that I sent to both Minister MacKay and to the CDS in response to comments made by LCol Jetly on the CBC's "The National".  The full list of references has been omitted for space.

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13 July 2011

To:

The Honourable Peter MacKay
Minister of National Defence

General Walter Natynczyk
Chief of Defence Staff

IN DEFENCE OF VIRTUAL REALITY EXPOSURE THERAPY

Sirs,

I write to you today in response to comments made by LCol Jetly of the Canadian Forces Health Services regarding the possibility of utilizing Virtual Reality Exposure Therapy (VRET) in the treatment of members of the Canadian Forces diagnosed with Post-Traumatic Stress Disorder (PTSD) or other operational stress injuries.

On the 14 June 2011 broadcast of the CBC’s “The National” (http://www.cbc.ca/thenational/indepthanalysis/story/2011/06/14/national-posttraumaticstressdisorder.html), at 06:45 minutes in the segment entitled “Effort to combat PTSD”, when questioned on why the Canadian Forces are not using Virtual Reality Exposure Therapy as a treatment for soldiers with Operational Stress Injuries, LCol Jetly responded: “We have a responsibility to our soldiers and to the tax payers, to provide evidence-based, best-practices … things that are published in peer-reviewed journals, that have multiple studies that show there’s benefit to it.”

I am at a loss to understand LCol Jetly’s apparent stance that VRET is not a tested and peer-reviewed treatment method, given that there have been numerous peer-reviewed publications, including case reports and clinical trials reports, dating back to 1995.

Both cognitive behavioural and exposure therapy have been used, and proven efficacious, in the treatment of a variety of psychiatric conditions (Gerardi et al., 2010; Meyerbröker & Emmelkamp, 2010), including PTSD, and VRET simply builds on this basis by providing a more immersive form of exposure (Gamito et al., 2010; Gorini & Riva, 2009; Rizzo et al., 2011; Wiederhold & Wiederhold, 2010; Wood et al., 2010), allowing the patient to process the emotional aspects of their traumatic event within a comprehensive and continuous therapeutic setting (Freedman et al., 2010; Wiederhold & Wiederhold, 2010; Wood et al., 2010).

Previous studies have shown the effectiveness of VRET in reducing symptomatology and increasing self-efficacy in a number of anxiety-spectrum conditions, including acrophobia (Choi et al., 2001; Coelho et al., 2006; Coelho et al., 2008; Emmelkamp et al., 2001), arachnophobia (Garcías-Palacios et al., 2001; Michaliszyn et al., 2010), aviophobia (Rothbaum et al., 2006; Wiederhold & Wiederhold, 2003), claustrophobia (Botella et al., 1999; Malbos et al., 2008), obsessive-compulsive disorder (Kim et al., 2008; Kim et al., 2009), post-traumatic stress disorder (Botella et al., 2010; Difede & Hoffman, 2002; Difede et al., 2007; Freedman et al., 2010; Gamito et al., 2010; Gerardi et al., 2008; Josman et al., 2008; McLay et al., 2010; McLay et al., 2011; Ready et al., 2010; Reger et al., 2011; Riva et al., 2010; Rizzo et al., 2010; Rizzo et al., 2011; Rothbaum et al., 1999; Rothbaum et al., 2001; Rothbaum et al., 2010; Tworus et al., 2010; Wiederhold & Wiederhold, 2010; Wood et al., 2010), and social phobia (Harris et al., 2002)

Aside from being more easily implemented than in vivo exposure, VRET allows for a more patient- and therapist-controlled experience during exposure than previous in vivo exposure techniques (Coelho et al., 2008; Freedman et al., 2010; Riva et al., 2010; Rothbaum et al., 1999; Wiederhold & Wiederhold, 2010), and removes many of the ethical concerns surrounding such methods (Olatunji et al., 2009), especially when dealing with anxiety-spectrum disorders and their associated symptomatology.  Importantly, when patients in several studies were given a choice between standard in vivo exposure therapy and VRET, the patient preference highly favoured VRET (García-Palacios et al., 2001; Wilson et al., 2008).  It should be obvious that if a patient favours a specific form of treatment, they are far more likely to not just seek that treatment, but adhere to the treatment throughout its course.

VRET also provides more stimuli to re-experience the traumatic event than imaginative exposure techniques within a similar therapeutic setting (Difede & Hoffman, 2002; Gamito et al., 2010; Gerardi et al., 2008; Gerardi et al., 2010; Josman et al., 2008; Kim et al., 2009; Ready et al., 2010; Reger et al., 2011; Rizzo et al., 2011; Rothbaum et al., 2001).  By the very nature of VRET, it is more easily tailored to the individual patient that most in vivo exposure therapies, at the very least is no less effective than traditional exposure therapies (Gamito et al., 2010; Michaliszyn et al., 2010; Powers & Emmelkamp, 2008; Ready et al., 2010; Rothbaum et al., 1999), and is a generally low-cost treatment method (Botella et al., 2010; Emmelkamp et al., 2001; Kim et al., 2009; Wiederhold & Wiederhold, 2010).

The key strengths of VRET is that it allows the therapist to gradually increase the level of immersion and exposure presented to the patient, while also allowing the patient to control their own degree of immersion and exposure, thereby allowing the patient to be more integral within their treatment and therefore regain a degree of control over their emotional responses to the traumatic events that were causal in their operational stress injury (Gamito et al., 2010; Gerardi et al., 2008; Rizzo et al., 2011; Wood et al., 2010).  This degree of patient-control leads to normalization of their emotional arousal, and allows them to adapt their self-efficacy and resilience in similar situations when a state of hyper-arousal occurs in their day-to-day lives, leading to a reduction in symptomatology and a stabilization of their condition (Freedman et al., 2010; Gerardi et al., 2008; Josman et al., 2008; McLay et al., 2010; Rizzo et al., 2011; Tworus et al., 2010; Wiederhold & Wiederhold, 2010).

Of particular note, VRET can be utilized as a treatment method in-theatre for the treatment of soldiers experiencing acute PTSD or who have been redeployed subsequent to prior treatment for combat-exposure-based PTSD (McLay et al., 2010).  This is of importance given further comments made by LCol Jetly in the same episode of the CBC’s “The National”, at 06:13 minutes of the clip titled “Soldiers suffering from PTSD redeployed”:

Interviewer: “Do you have any concerns about sending someone back who has already developed PTSD, not withstanding that they may have received treatment and that they seem better?  Do you concerns about the impact on them of going back?”

LCol Jetly: “Yeah, I mean that’s … The academic question hasn’t been answered in terms of is this harmful to people, so, yes, as a treating psychiatrist I have concern.  I have very little concern if I’m confident the treatment has gone well.  The civilian rule of thumb is sort of a third of people recover fully from PTSD.  You know, full recovery means no longer symptomatic.”

Interviewer: “Does it mean cured?”

LCol Jetly: “Yeah … In my … There’s a huge debate about that.  I would use the word cured.”

Aside from the controversy arising over LCol Jetly’s comment that PTSD can be “cured” (not a view held by myself, nor any soldier or veteran that I have met who has been diagnosed and treated for an operational stress injury, including PTSD), if indeed we are to redeploy Canadian Forces personnel who have had previous treatment for PTSD, I would argue that we should make every effort to have effective treatment methods in place and available in-theatre to assist in reducing the effects of subsequent PTSD re-emergence amongst those individuals.  McLay et al. (2010) report that amongst patients treated by VRET at a mental health clinic in Camp Fallujah, Iraq, all patients showed significant stabilization and not a single medical evacuation due to PTSD occurred amongst the treated service members.

To reject Virtual Reality Exposure Therapy on the basis that it is an untested therapeutic tool, or on the basis that it is not a cost-effective method of treatment, is folly.  I urge the Canadian Forces and the Department of National Defence to review the decision not to utilize this treatment method.


Militi Succurrimus



Walter Callaghan
Medical/Psychological Anthropologist
Former Officer, Canadian Forces Health Services
Disabled Veteran

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