Based on the need for continued, iterative soldier feedback and a desire to formalize a data collection methodology, the authors launched a study of previously deployed soldiers’ feedback (Reger et al., 2009) of the evolving Virtual Iraq/Afghanistan VRET system, the design of which was informed by the initial feedback from soldiers in Iraq. Soldiers who had been home from Iraq or Afghanistan for less than a year were recruited to use and evaluate the current system.

The Virtual Iraq/Afghanistan application developed at the time (2006–2007) comprised of a series of virtual scenarios including a Middle-East themed city and roadway environments (See Fig. 15.3). The scenarios were designed to resemble the general contexts that most SMs would have experienced during a deployment to Iraq or Afghanistan. The 18-square block City setting had a variety of elements including a marketplace, desolate streets, old buildings, ramshackle apartments, warehouses, mosques, shops, and dirt lots strewn with junk. Access to building interiors and rooftops was available and the backdrop surrounding the navigable exposure zone created the illusion of being embedded within a section of a sprawling densely populated desert city. Vehicles were active in streets and animated virtual pedestrians (civilian and military) could be added or eliminated from the scenes. Users could be teleported to specific locations within the city, based on a determination as to which environments most closely matched their experiences.

The Iraq Desert road scenario consisted of a roadway through an expansive desert area with sand dunes, occasional areas of vegetation, intact and broken down structures, bridges, battle wreckage, a checkpoint, debris, and virtual human figures. The system also had an Afghanistan-themed road scenario that contained similar elements but within a more mountainous terrain context that included Afghan style architectural and cultural elements. In both the Iraq and Afghanistan roadways, the user could be positioned inside of a HUMVEE that supported the perception of travel within a convoy or as a lone vehicle with selectable positions as a driver, passenger, or from the more exposed turret position above the roof of the vehicle. Both the city and HUMVEE scenarios were adjustable for time of day or night, weather conditions, night vision, illumination, and ambient sound (wind, motors, city noise, prayer call, etc.). Users could navigate in both scenarios via the use of a standard gamepad controller.

In addition to the visual stimuli presented in the VR Head-Mounted Display (HMD), directional 3D audio, vibrotactile and olfactory stimuli could be delivered into the VR scenarios in real time by the clinician. The presentation of additive, combat-relevant stimuli in the VR scenarios could be controlled via a “Wizard of Oz” control panel, while the clinician was in full audio contact with the patient. This clinical “interface” provided the clinician with the capacity to customize the therapy experience to the individual needs of the patient. The patient could be placed by the clinician in VR scenario locations that resembled a setting relevant to their trauma experience and modify ambient light and sound conditions to match the patient’s description of their experience. The interface also allowed the clinician to gradually introduce and control trigger stimuli in real time to foster the anxiety modulation needed for therapeutic habituation and emotional processing in a customized fashion according to the patient’s past experience and treatment progress. Such options for real time stimulus delivery flexibility and user experience customization were considered to be key elements for this application. Trigger stimuli included a variety of auditory stimuli (e.g., incoming mortars, weapons fire, voices, wind), dynamic audiovisual events including helicopter flyovers, bridge attacks, exploding vehicles and IEDs, and olfactory stimuli (e.g., burning rubber, gunpowder, garbage, diesel fuel). In contrast to the VR system taken to Iraq, this study added a platform with bass shaker speakers. These speakers enabled low frequency sounds (e.g., virtual explosions or the idle of the vehicle) to also be experienced as vibrations by participants.

Soldiers responded to a series of likert scale items ranging from 1 (poor) to 10 (excellent), with the midpoint of 5 representing an adequate rating. Ninety-three soldiers provided feedback. Although the average evaluation was between adequate and excellent for all rated aspects (see Table 15.1), additional needed improvements were identified. For example, soldiers felt it was unrealistic to stand on a platform and navigate in a foot patrol scenario holding a gaming joystick. A number of participants reported that realism would be enhanced if they were holding their weapon. Both environments were judged too clean. Soldiers recommended more debris, dirt, and garbage. Soldiers also found it unrealistic to be seated in a virtual vehicle or walking through an Iraqi city alone. They requested the presence of additional soldiers. Additional Iraqi civilian pedestrians were requested and the possibility of more congested traffic was recommended. Soldiers also suggested the development of a library of tactical vehicles and weapons that could be selected based on the personal experience of the soldier.

These two efforts resulted in a number of key improvements to the Virtual Iraq/Afghanistan system. Changes included the adaptation of a mock M4 rifle with a mounted mini joystick, allowing soldiers to navigate through the virtual city in a naturalistic fashion, while holding the physical prop of a realistic weapon. Truck commanders, turret gunners, and passengers were added and both environments were improved with additional pedestrian and vehicle traffic. Among other improvements, recommendations regarding the inclusion of animal carcasses, dirt, and garbage were implemented.

Feedback received from the intended end users was essential to the development of a useful Virtual Iraq/Afghanistan system. More importantly, the development of an improved system enabled successful treatment protocol development and clinical application. The VR Iraq/Afghanistan system has been used for the effective exposure therapy treatment of members of the National Guard (Gerardi, Rothbaum, Ressler, Heekin, & Rizzo, 2008) as well as active component soldiers (Reger et al., 2011; Reger & Gahm, 2008; Rizzo et al., 2011). Well-designed randomized controlled trials are currently underway to determine the efficacy of VRET relative to existing standards of care. Based on the initial success of the use of this approach for the delivery of exposure therapy using VR, the U.S. Department of Defense has funded the development of an updated and expanded version of the Virtual Iraq/Afghanistan system built from currently available software. This work will be detailed in the chapter by Rizzo et al. (2014) in this volume.

Change is difficult. This appears to be as true of mental health practitioners as anyone. Research has demonstrated that adoption of evidence-based psychotherapies by clinicians is slow, despite significant research supporting efficacy (Frueh, Grubaugh, Cusack, & Elhai, 2009). A survey of 207 licensed psychologists found that only 9 % reported using imaginal exposure with 50 % or more of their PTSD patients (Becker, Zayfert, & Anderson, 2004). The primary factor limiting use of imaginal exposure was limited training (Becker et al., 2004). Similarly, when 296 trauma experts were asked to what extent they agreed with the statement that they had received good training in imaginal exposure, their average response was lukewarm. On a scale from 1 to 10, with 10 representing strong agreement, the average response was 3.76 (SD = 3.03, van Minnen, Hendriks, & Olff, 2010). It is not surprising that only a minority of these therapists used exposure to treat their PTSD patients.

Development of a new, promising innovative treatment does not guarantee adoption and implementation, even by interested early adopters and researchers. Adequate training is required. Furthermore, researchers or clinicians seeking to study or implement VRET need training to build on existing best practices. In October 2008, we had received enough requests for VRET training that we began hosting clinical training workshops to assist Veterans Administration (VA) and Department of Defense (DoD) researchers and providers who were seeking to learn current best practices for this promising emerging treatment.

The training approach was carefully considered with an eye towards the likely audience, necessary prerequisite knowledge, and common factors affecting implementation (Ruzek & Rosen, 2009). According to Fixsen and colleagues, as cited in Ruzek and Rosen (2009), the impact of training workshops increases when skill demonstration and rehearsal are included. We also wanted to build in opportunities for post-training consultation and supervision to support an ethical model of new skill acquisition (American Psychological Association, 2002) and to assist with post-training consolidation of learned skills (Ruzek & Rosen, 2009).