Inside this issue

	



 National

Center

for

PostTraumatic

Stress

 Disorder Menlo Park/Palo Alto * Boston * Honolulu * West Haven * White River Junction

Following the crash of American Airlines 77 into the

Pentagon, the immediate medical response was a mission to

evacuate and treat the wounded. Within hours, however, it

became apparent that the dead were many and the wounded

were few. The response thus turned to become one to provide

mental health support to the survivors, the rescue workers,

the family members of the victims, and other affected

personnel.

Teams and individuals from the Department of Defense,

the Red Cross, the National Center for Post Traumatic Stress

Disorder (NCPTSD) from the Department of Veterans Affairs

(VA), and many others provided assistance. This article briefly

outlines their efforts, and some of the mental health

interventions used. Hundreds of people participated in these

interventions, and have their own perspectives; this essay

outlines an overview from the author’s experience, and

incorporates what she learned from others. The account is

hardly a comprehensive one. A forthcoming supplement to

Military Medicine should develop many other accounts. Others

did much of the hard work, and this author wants to

acknowledge their contributions.

The literature on disaster is, fortunately or not, growing

exponentially. It is reviewed elsewhere (1, 2).

The Event

Shortly after two airplanes smashed into the World Trade

Center on the morning of September 11th, a third hit the

south side of the Pentagon. Those in the affected wedge heard

a boom, and depending on how close they were, saw, smelled

and heard smoke and fire. Some had to struggle to get out,

and were often aided by colleagues or the first responders.

However, many in the far side of the Pentagon did not even

feel the crash.

Elspeth Cameron Ritchie, M.D.

Dr. Ritchie meeting President Bush

Many rescuers worked outside the Pentagon to aid the

wounded. Initially, most of the severely injured were brought to

the central courtyard. They were immediately airlifted to local

hospitals, including the burn unit at the Washington Hospital

center. Only a few were brought to local military hospitals. After

a relatively brief period of time, everyone requiring medical

treatment was evacuated.

The entire

building was

immediately

evacuated in an

orderly

fashion, including the day care

center, on the

north side. Several times there

were reports of

other planes

approaching,

and the rescuers

 needed to evacuate the crash site for fear of more plane bombs. One

hundred eighty-nine people were killed in the crash, to include

Pentagon personnel, the airplane passengers and crew, and the

highjackers.

Mental Health Response to the Pentagon after 9/11: An Overview 53

New Directions 60

Early Intervention: A Clinical Forum 61

Virtual Reality Based Exposure Therapy With Vietnam Veterans 62

Activities Immediately After the Crash

Each branch of the military service boasts a hospital in

the Washington DC area: Walter Reed Army Medical Center

(WRAMC), National Naval Medical Center (NNMC or

“Bethesda”), and Malcolm Grow Medical Center (MGMC)

at Andrews Air Force Base. Immediately following news of

the attack, the hospitals implemented their respective disaster

plans and team procedures for providing emergency medical

	



		
	

		





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In this issue, the Clinical Quarterly continues its series of articles about emergency mental health services in

response to disasters. Elspeth Cameron Ritchie provides a first hand account of the complex mental health service

response coordination within Department of Defense (DoD) and between DoD and several federal, non-profit, and

local agencies following the 9/11 attack on the Pentagon. A multi-tiered service effort to provide support to primary,

secondary, and tertiary victims is described. Dr. Ritchie was later instrumental in organizing the Consensus Workshop

on Mass Violence and Early Intervention that took place in Virginia in November, 2001. The conference, hosted by

DoD, Department of Justice, NIMH, VA/NC-PTSD, and American Red Cross, brought disaster mental health

experts from around the world to examine critical issues related to screening, practice guidelines, training, ethical

consideration, research, etc. Work is underway to publish “Proceedings of the Mass Violence and Early Intervention

Expert Consensus Conference.”

This issue also features the creative and ground-breaking work of the Atlanta VAMC Post-Traumatic Stress

Disorder Clinical Team and their colleagues at Georgia Tech University. Through their efforts to integrate empirically-validated treatment with new technology, David Ready, Barbara Rothbaum, and Larry Hodges have created and

begun preliminary evaluation of PTSD treatment that could not only be potentially more powerful than other

exposure-based therapies, but that could have application in the treatment of other anxiety disorders such as panic or

social phobias. Having recently adorned the equipment (head mounted display) myself to receive a computer generated “tour,” it was easy to imagine the potential therapeutic benefits and easy to appreciate the excitement the Atlanta

team has for undertaking a rigorous evaluation for its use as a component of PTSD treatment.

Bruce H. Young, Editor-in-Chief
	

		





					

			 !

The Days and Weeks after the Attack

A wide variety of activities commenced immediately after

the attack. The bulk of the mental health personnel were deployed

to the Pentagon itself. Group sessions were offered at the crash

site, in the workplace, and in the DiLorenzo clinic. Many

workplaces were destroyed, so often sessions were conducted in

makeshift spaces. Individuals were seen at the clinic and the

crash site on a walk-in basis. Group interventions (“debriefings”)

were offered on a regular basis, at the health clinic, crash site,

and in work areas.

A Navy team deployed to the Navy Annex, which is a large

building overlooking the Pentagon. The bulk of Navy personnel

who had been located in the Pentagon were re-located there.

The Air Force also developed a separate operations center, for

outreach to the Air Staff personnel. Staff from Keesler AFB

joined the overall effort on September 15th.

Outreach to the entire Pentagon was undertaken a few days

after the attack. From other disasters and experiences within

the military, it was clear that many would not go into a mental

health clinic, but would respond to outreach. Fortunately, this

was not only supported, but initiated, at the highest levels of

command. Maps showing the sections were used. Teams walked

through these areas to contact, distribute a specially developed

flyer, and to help people become aware of the services that could

be provided. The Employee Assistance Program, located in the

Civilian Occupational Clinic (part of the DiLorenzo Clinic),

and mental health care. Assets from Ft. Belvoir and Bolling

AFB also joined the effort.

 Chaplains and mental health personnel were immediately

deployed to the crash site and to the DiLorenzo health care

clinic in the Pentagon, which quickly became the Operations

Center for the mental health response throughout the Pentagon.

Army and Air Force personnel principally operated out of that

clinic. A Navy team de-ployed to the Navy Annex.

The Pentagon houses 24,000 personnel, and another

16,000 work in buildings near or adjacent to that building.

Of the 24,000, approximately ten thousand are military or

DoD (Department of Defense) civilian employees; the rest

are contractors.

Wounded individuals were primarily first treated in local

hospitals. The psychiatry consult liason service from Walter

Reed worked with many of the hospitalized wounded. Others

were seen in their local emergency rooms and referred to

mental health if needed.

The views expressed in this article are those of the author and do

not reflect the official policy or position of the Department of

Defense or the U.S. Government.

provided treatment and referrals to civilian employees. Civilian

employees and contractors, not officially eligible for military

health care, were encouraged to participate in both individual

and group interventions.

Many people officially assigned to the Pentagon work in

adjacent offices, such as in Hoffman and Skyline Buildings. In

addition, organizations whose offices were destroyed were

relocated to buildings such as the Taylor Building. Group and

individual assistance was also offered to all these locations.

A few other examples of distress follow: a) a worker who

was very perturbed that he had followed the orders to evacuate,

rather than try to return to rescue others; b) workers who worked

in adjacent building, but had lost dozens of their long term

colleagues; c) day care staff who thought that they would lose

their jobs, because only a fraction of the children returned to

the Pentagon Day Care Center; and d) several employees

appeared who were spooked by the sounds of safes being

unloaded—they thought it was another bomb.

As previously mentioned, the childcare center was evacuated

immediately after the attack, and closed for the next ten days.

Children therefore had to endure not only the sights of the

bombing but also the re-location and change of caretakers. Their

parents were working long hours, in preparation for war. The

mothers of two children were killed. Child psychiatrists, first

from Children’s Hospital and then from Walter Reed, worked

with the staff and children there.

...it was clear that many

would not go into a mental

health clinic, but would

respond to outreach.

Fortunately, outreach was

not only supported, but

initiated, at the highest

levels of command.

The Family Assistance Center

Each Service (Army, Navy, Air Force) initially began to set

up their own Family Assistance Center. However, the day

following the event, a consolidated triservice Family Assistance

Center was organized in a hotel in Crystal City, near the
	

		





Therapeutic Activities

A variety of therapeutic activities were employed. The term

“debriefing” was used, but seldom was a formal “Critical Incident

Stress Debriefing” or “CISD” utilized (3-5.) Usually the group

intervention activities were tailored to the group and their

particular situation. Groups were run several times daily in the

DiLorenzo Clinic, both for specific workplaces and for walkins. Individual supportive therapy was offered, again both in

the clinic and as part of the outreach. Meetings with the

workplace often focused on “repairing the organizational fabric”.

All mental health disciplines were represented in the effort,

to include psychiatric nurses and occupational therapists.

Chaplains provided spiritual and therapeutic services, both

through individual and group work, and through memorials

and remembrances in the workplace. Their tent was prominent

at the opening for the crash site.

Special mention should be made of the work provided to

members of the Old Guard. Those young infantry soldiers,

Continued on page 59



Pentagon. This was organized and staffed by DoD, with support

from all the Services. Those eligible were family members of all

the victims, including military personnel, civilian employees,

contractors, and airline passengers.

This DoD Family Assistance Center provided a wide range

of services. The general in charge provided briefings twice daily.

Each family had assigned to them a casualty assistance care officer

(CACO). Personnel from the Office of Victims of Crime

(OVC), the Red Cross, the Federal Emergency Management

Agency (FEMA), and the different Service relief agencies offered

financial and supportive services. The Armed Forces Institute

of Pathology (AFIP) gathered DNA from family members to

assist in identification. There was a robust presence from

chaplains, medical and mental health assets (including child

psychiatrists), and volunteers. Pet therapy was also available.

Hundreds of families gathered at this hotel. The ballroom, the

main briefing room, became a shrine. From the author’s

perspective, some of the most poignant moments involved

watching the children play in the room and the hotel, not yet

truly realizing the loss of a parent or grandparent. The

environment was very intense.

The general in charge did a heroic job of working with the

families, as did all the staff of the center. A team from the

National Center for PTSD (part of the VA) joined this effort.

They primarily worked with the staff of the assistance center,

to help them process their work with the victim’s families. Many

of the staff who had lost friends in the attack, worked continuously

with the families for the following month. The counselors paid

special attention to the hotel staff as they knew of the severe stress

on ancillary staff through working with other disasters.

Operation Solace

Consultants to the Army Surgeon General and other Army

medical staff developed a long-range plan for provision of

care. Using data from the Oklahoma bombing and other acts

of terror and disasters, they sought to project the need for

mental health care over the weeks, months and years after

the attack (1, 2, 9-11). Resources were then deployed to

meet those anticipated needs.

Mental health assets were placed on a long-term basis at

the DiLorenzo Clinic, in a conference room in the Pentagon

area, and at the Taylor and Hoffman Buildings. At this

time (March, 2002), overall psychiatric morbidity is less

stationed at nearby Ft. Myers, who usually guard the Tomb of

the Unknown Soldier and work at funerals, were responsible for

entering the smoking hole in the Pentagon and clearing debris.

They were provided information about dealing with dead bodies

and given a chance to discuss their experiences in the mental

health tent at the end of each shift (Tables 1 and 2). In general,

both command and soldiers were receptive to the briefings (6-

8).

Similarly individual contact and group meetings were offered

to other personnel at the crash site, including first responders,

the criminal investigative services and mortuary affairs. These

personnel were, in general, seasoned professionals, and did not

seek out counseling—although they were probably comforted

by the aid offered there. Little yet is known, by this author,

about any long-term reactions.

A team also was deployed to Dover, where the task of

identifying remains was centralized. The team working there

drew in the experience of more senior staff to help the junior

staff with coping with the grisly tasks.

Coordination

Special efforts were needed to coordinate interventions,

both between the Services, and between DoD, the VA, the

Red Cross, local governments, and other agencies. Conference

calls were held for four afternoons following the attacks. Email was used extensively. These mechanisms helped reduce

unnecessary over-lap and minimized gaps in areas of need.

The Red Cross helped to coordinate efforts between

governmental and non-governmental agencies and volunteers.

The American Psychological Association picked up that

function after the departure of the visiting Red Cross workers.

At those meetings, representatives from the federal

government (SAMHSA, NIMH), different local governments

(DC, MD, VA), the different professional associations (APA,

APA, NASW), and local hospitals and military members met

to exchange information.
	

		

 



					

			 !

Table 1. When The Mission Requires Recovering Human Dead Bodies: How to Prepare Yourself, Your Buddies, and the Unit

SOURCE: Combat Stress Actions Office; MCCS-HPO, Dept. Preventive Health Services, AMEDDC&S, FSH, TX, 78234-6142, DSN 471-6985, commercial (210) 221-6985

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SOURCE: Combat Stress Actions Office; MCCS-HPO, Dept. Preventive Health Services, AMEDDC&S, FSH, TX, 78234-6142, DSN 471-6985, commercial (210) 221-6985

Table 2. Guidelines for How to Work with Human Remains

  
	

		

"



7. McCarroll, J.E., Ursano, R.J. & Ventis, W.L. (1993).

Anticipation of handling the dead: Effects of gender

and experience. British Journal of Clinical Psychology,

32, 466-468.

8. McCarroll, J.E., Fullerton, C.S., Ursano, R.J., & Hermsen,

J.M. (1996). Posttraumatic stress symptoms following

forensic dental indentification: Mt Carmel, Waco,

Texas. American Journal of Psychiatry, 153, 778-782.

9. McFarlane, A.C., & Girolamo, G.D. (1996). The nature

of traumatic stressors and the epidemiology of

posttraumatic reactions. In B.A. Van derKolk, A.C.

McFarlane, & L. Weisach (eds.), Traumatic stress: the

effects of overwhelming experience on mind, body,

and society. New York: Guilford Press.

10. Oklahoma Department of Mental Health and Substance

Abuse Services. (1998). A report on Project Heartland,

Oklahoma crisis counseling services for those affected

by the Murrah Federal Building Bombing on April

19, 1995. Final Report FEMA regular crisis counseling

services grant, May 31, 1998.

11. Bryant R.A., & Harvey A.G. (2000). Acute stress disorder:

A handbook of theory, assessment, and treatment.

Washington, DC: American Psychological Association.

Dr. Elspeth Cameron Ritchie is a psychiatrist and Program

Director of Mental Health Policy and Women’s Health Issues,

Office of the Assistant Secretary of Defense/Health Affairs. LTC

Cameron Ritchie graduated with a Bachelor of Arts Degree in

Biology and Folklore and Mythology from Harvard College,

and received her medical degree from George Washington

University. LTC Ritchie entered active duty in 1986 and after

serving in Korea and Somalia, held several positions at Walter

Reed Army Medical Center including Chief, Community

Psychiatry, Assistant Chief of Outpatient Psychiatry, Chief of

Inpatient Psychiatry, and Chief of the Forensic Psychiatry

Services. Her awards include the Expert Field Medical Badge,

Humanitarian Medal, Army Commendation Medal (with three

oak loaf clusters), Army Achievement Medal and the Army

Good Conduct medal. She has numerous professional

publications in journals and textbooks and testifies frequently

as an expert witness.

					

			 !

than feared, perhaps partly due to the intensive efforts

described above.

Conclusion

The tragedy of September 11 has shaken and traumatized

the country. Subsequent anthrax threats turned the issue from

an acute stress to a chronic one. The response from mental

health and chaplain personnel from the Department of Defense

to the Pentagon tragedy was comprehensive and immediate.

Challenges did arise, however, as different agencies integrated in

providing services.

References

1. Norris, F.H. (2001). 50,000 Disaster Victims Speak: An

Empirical Review of the Empirical Literature, 1981 –

2001. Unpublished manuscript prepared for The National

Center for PTSD and The Center for Mental Health

Services (SAMHSA).

2. North C.S., Nixon S.J., Shariat, S., Mallonee, S., McMillen,

J.C., Spitznagel, E.L., & Smith, E.M. (1999). (1999).

Psychiatric disorders among survivors of the Oklahoma

City bombing. Journal of the American Medical

Association, 62, 755-762.

3. Wessely, S., Rose. S., & Bisson. J. (1999). Brief psychological

interventions (‘debriefing’) for immediate trauma related

symptoms and the prevention of post traumatic stress

disorder (Cochrane Review). The Cochrane Library, 4.

Oxford: Update Software.

4. Weisæth, L. (2000). Briefing and Debriefing: Group Psychological

Interventions in Acute Stressor Situations. In, B. Raphael

& J. P. Wilson (eds.), Stress Debriefing: Theory, Practice

and Evidence (pp. 43-57). London: Cambridge University

Press.

5. Raphael, B. & Wilson, J.P. (2000). Introduction and overview:

Key issues in the conceptualization of debriefing. In B.

Raphael & J.P. Wilson (eds.), Psychological Debriefing:

Theory, Practice and Evidence (pp. 1-14). Cambridge

University Press.

6. Ursano, R.J. & McCarroll, J.E. (1990). The nature of a

traumatic stressor: Handling dead bodies. Journal of

Nervous & Mental Disease, 178, 396-398.
	

		

	



 	
  	
 	

	
		
	





 	
 
 
 
 
      


  
 

We are extremely pleased that VA’s Cooperative Studies Program has funded another National Center multi-site psychotherapy treatment

trial, VA Cooperative Study #494 (CSP #494) “A Randomized Clinical Trial of Cognitive-Behavioral Treatment for PTSD in Women.”

The study is distinctive in several ways. It represents a collaboration between VA and the Department of Defense (DoD). Vet Center sites are

included along with VA Medical Center (VAMC) sites. Both female veterans and women on active duty in the military will participate. The study

will test a form of cognitive-behavior therapy, Prolonged Exposure (PE), that has the greatest amount of empirical support and it will be the largest

individual psychotherapy trial for PTSD ever conducted.

Co-chairs of the project are LTC Charles Engel MD from Walter Reed Army Medical Center, and the two of us from the National Center

for PTSD (Paula is head investigator on this study). The twelve participating facilities include one DoD site at Walter Reed in Washington, DC;

two Vet Center sites at Bay Pines/Tampa, FL and Denver, CO; and nine VAMC sites at Albuquerque, NM, Atlanta, GA, Baltimore, MD, Boston,

MA, Cincinnati, OH, Cleveland, OH, Dallas, TX, New Orleans, LA, and Portland, OR. (When we include the eight other centers that

participated in our previous cooperative study, CSP420: Group Therapy for PTSD, a total of 17 different VAMCs, 2 Vet Centers, and one

military medical center have been included in National Center-sponsored multisite psychotherapy treatment trials, in recent years.)

We are also extremely fortunate to have the support of VA’s Cooperative Studies Program Coordinating Center in Palo Alto, headed by Phil

Lavori with Ken James as Study Biostatistician and Maryann Boeger as Administrative Officer. Our Executive Committee includes many of the

top American experts in PTSD treatment and/or women’s mental health: Edna Foa, Tracie Shea, Patti Resick, Terry Keane, Bob Rosenheck, Rod

Haug, Sue Orsillo, and Carole Turner.

Female military personnel, hence female veterans, have a higher prevalence of PTSD than their civilian counterparts. A recent Navy and

Marine Corps study found that among women on active duty, 17.4% had lifetime PTSD and 8.3% had current PTSD. Female Vietnam veterans

were estimated to have 26.0% lifetime and 8.5% current PTSD. These findings contrast with findings among civilian women where lifetime and

current PTSD prevalence are 10.4% and 2.7%.

Because PTSD cannot develop unless an individual has been exposed to traumatic stress, it’s important to consider both military and premilitary

exposure. Military trauma in women most often involves sexual assault or rape although it may also involve physical assault, accidents, disasters, war

zone exposure and, for women assigned to medical/nursing duties, it may include exposure to wounded, dying and dead active duty personnel and

indigenous civilians. To compound this issue, a significant number of women experience trauma prior to joining the military. Indeed, several

studies have found higher prevalence of exposure to childhood/adolescent sexual abuse among female military inductees than among civilian

comparison groups.

We cite these statistical findings to emphasize the significance of this study and the potential policy implications of our research findings.

Recognition of the magnitude and special needs of women has prompted VA to create specialized programs for female veterans and special

training for VA practitioners to promote effective and comprehensive treatment for women.

The study is a randomized clinical trial involving 384 female veterans and active duty personnel across 12 sites. If they meet entry criteria,

participants will be randomly assigned to one of two treatments: Prolonged Exposure (PE), or Present Centered Therapy (PCT), which focuses on

current problems rather than past trauma. Treatment will be delivered in 10 weekly sessions.

Participants will be assessed before treatment, immediately following treatment, and 3 and 6 months after the end of treatment. The primary

outcome is PTSD severity. Secondary outcomes are anxiety and depression. Exploratory outcomes include associated features of PTSD, such as

dissociation and substance abuse; psychosocial functioning, quality of life, physical health, satisfaction with treatment, and service utilization.

Training is a major component of CSP #494. Therapists will attend an intensive and comprehensive multi-day training session taught by each

Master Therapist at separate sites so that they learn how to utilize the treatment manual. Following this, each therapist will treat two pilot subjects

before being assigned to a subject in the study. Close supervision for all pilot and study cases will be provided to insure that subjects receive high

quality PE or PCT Therapy. This will be accomplished by having master therapists review selected videotapes of treatment sessions in order to

provide timely supervision of study therapists. Videotapes will also be reviewed by another team of expert consultants to evaluate the quality of PE

or PCT that had been delivered.

It’s hard for the uninitiated to appreciate the magnitude of this undertaking. Each study site will have seven individuals working on the study:

a site investigator, a site coordinator, an assessment technician, and four therapists. Because there are 12 sites, that makes 84 individuals. At Palo

Alto’s Cooperative Studies Program, there are additional personnel involved in study management and data processing. Additional staff in

Philadelphia, Providence, and St. Louis provide therapy supervision or perform fidelity monitoring. Finally, we must include the Co-Chairs’ office

at White River Junction. In short, well over one hundred people are making major contributions to CSP #494.

In closing, we want to specifically recognize Nancy Bernardy, Veronica Thurston, Kay Jankowski, and Moira Ripley in White River Junction

and Maryann Boeger and her staff in Palo Alto, who are the glue who hold this massive study together and the enforcers who keep us all on track.
	

		





		 	 	 
	 	
	

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Early intervention to prevent development of PTSD: Toward effective post-trauma education

Much of what is called early intervention is really simple education. That is, survivors are given information that is

intended to help them recover. As a relatively brief, non-stigmatizing, low-cost form of care, it may be delivered via

informal conversations or in structured formal presentations, but together with restoration of physical safety, social support, and practical help, educational information forms much of what is offered to survivors in the immediate aftermath of

trauma. Given the ubiquity of such education, it is useful to begin to think through this component of early intervention

to examine the degree to which it is likely to achieve its objectives, and to consider the limitations of education as an

intervention.

In most post-trauma settings, the psychoeducational component of early intervention is generally intended to achieve the

following kinds of goals:

· To help survivors better understand a range of post-trauma responses.

· To accomplish “normalization” of responses; that is, to influence survivors to view their post-trauma reactions as normal (e.g., not as reactions

 to be feared, not as signs of personal failure or weakness, not as signs of mental illness).

· To help survivors recognize the circumstances under which they should consider seeking further counseling.

· To inform survivors how and where they can access additional help, including mental health counseling.

· To increase use of social supports.

· To increase use of other adaptive ways of coping with the trauma and its effects (e.g., talking to others about the experience of trauma).

· To decrease use of problematic forms of coping (e.g., alcohol consumption, social isolation).

· To increase ability to help family members cope (e.g., information about how to talk to children about what happened).

It is likely that some of the objectives of early post-trauma education will be routinely achieved by existing educational practices. For example, such practices are probably effective in informing survivors about sources of mental health

counseling. It is also likely that education increases some of the concrete changes in behavior that are targeted, such as

reduction of alcohol consumption or use of formal counseling services. Verbal instigation of behavior change is a primary

tool of all counseling, and, in non-trauma treatment contexts, brief advice has sometimes been found to be as effective as

more intensive forms of help (e.g., in reducing alcohol intake). This may be particularly true when the required change is

easily within the repertoire of the survivor, as in the seeking of counseling. When desired behaviors require more complex

social performances (e.g., seeking social support), simple instruction may prove to be less effective than modeling. When

they involve possible increases in negative emotion (e.g., talking about the experience of trauma) or other disincentives,

other approaches, such as motivational interviewing, may be useful. Whether simple instruction that “trauma responses are

normal reactions to abnormal situations” accomplishes the complex of cognitive changes that may be grouped under the

concept of normalization is unclear, but perhaps unlikely.

Despite its routine application, little is known about the education component of early post-trauma care. For

example, studies have not examined the degree to which those receiving education retain information. This is an important

issue, given that acute stress reactions are likely to impair attention and memory processes. Ways of presenting and

structuring of information have yet to be systematically compared. Written materials will lend themselves particularly well

to such evaluation, since alternative forms of materials can be easily created and distributed, and given the demonstrated

efficacy of “bibliotherapy” in other domains of behavior, this is an extremely important line of research inquiry. While

educational materials have sometimes been adapted for use with children of different ages, adolescents, and for specific

groups of adult survivors (e.g., the elderly), the effectiveness of these materials has not been evaluated.

In the next decade, it is likely that theory will increasingly inform design of post-trauma education and that

systematic research will be brought to bear on this neglected arena of care. In the meantime, as helping professionals and

emergency responders, we will continue to be challenged to educate survivors of all kinds of traumas. It is important that

we think through the objectives of our educational activities and design our instruction so that it will have maximum

impact. Our presentations must be easy to comprehend, include repetition of key points, and summarize take-home

messages. It is especially important that we prepare and distribute written materials that correspond to our verballypresented material, so that survivors can digest them when they are ready to do so.

	   	
	

		






around an area

that feels like it is

about two acres

in circumference

and includes a

swampy area and

several rolling

hills. In each

environment the

therapist can

turn on and off

sight and sound

effects such as

machine gun fire,

explosions and fog as needed. These environments respond to

the patient’s behaviors in a variety of ways that assist in making

them seem real. For example, as the patients look up they see

the sky, as they look down they see the ground, and they

have a 360-degree view of the virtual world around them. As

in the real world, when they move closer objects appear larger

and as they move away from them objects appear smaller.

Sounds are directional as well. For example, in the landing zone,

the patient can hear helicopters approaching. They get louder as

they come nearer and when one takes off the sound fades as it gets

farther away. These elements combine to quickly fool the senses.

For example, when the patient navigates in the swamp, he has the

sensation of going down into the mud a few inches and hears a

sloshing sound as he moves through it. Sound effects include mortars,

rockets, machine gun fire, yelling, land mines, distant B 52 strikes,

combat noises from a nearby battle, sloshing sounds in the swamp,

radio chatter and a variety of helicopter sounds. Visual effects include

helicopters coming in and flying out and flying over, muzzle

flashes, fog, a bright flash as the land mine explodes, and darkness.

VIRTUAL REALITY BASED EXPOSURE THERAPY

WITH VIETNAM VETERANS WHO SUFFER FROM PTSD

David J. Ready, Ph.D., Barbara O. Rothbaum, Ph.D., ABPP, and Larry Hodges, Ph.D.

Virtual Reality is a revolutionary new computer

technology that gives the patient a sense of presence in a highly

interactive, computer-generated environment that has been used

for psychotherapeutic purposes. What makes VR different than

looking at a picture or seeing a movie is that the patient has the

sense of being immersed within an environment that responds

to his/her behavior in much the same way the real world

does. VR exposure has been shown to be effective in treating

specific phobias (4). This paper describes the application of

VR exposure to PTSD in Vietnam combat veterans.

Virtual Reality opens up the possibility of

providing exposure that is near in vivo

quality without the potential hazards and

inconvenience of real in vivo exposure.

A recent meta-analysis of 61 Posttraumatic Stress Disorder (PTSD) outcome studies found greater efficacy for exposure therapy than for any other type of PTSD treatment as

measured by clinician-rated changes in PTSD symptoms (1).

Exposure therapy is aimed at facilitating emotional processing

(2). For this to occur, it has been proposed that the fear structure must be activated and modified. Exposure therapy is historically effective at activating the fear structure via confrontation with the feared stimuli, which elicits the fearful responses.

With PTSD the feared stimuli can be the patient’s memory of a

traumatic event. The processes of habituation and extinction,

in which the feared stimuli cease to elicit anxiety, aid modification of the fear structure, making its meaning less threatening.

Any method capable of activating the fear structure and modifying it would be predicted to improve symptoms of anxiety.

Thus, Virtual Reality (VR) exposure has been proposed as another medium for exposure therapy (3). What distinguishes VR

from a mere multimedia system or an interactive computer graphics display is a sense of presence. A sense of presence is essential

to conducting exposure therapy.

This collaborative effort between the Atlanta VA

Medical Center, Emory University and Georgia Institute of

Technology uses two Virtual Vietnam environments. One is a

Huey helicopter ride that travels over several different types of

Vietnam-like terrain (jungle, rice paddies, river) and that lands in a

hot landing zone. The other is a landing zone-like environment in

which the patient can, through the use of a joystick, “walk”

 In this treatment, patients wear a Head Mounted

Display (HMD), which covers their eyes and ears. In the HMD

they look straight into two mini-television screens that take up

most of their visual field and wear large earphones. The computer

screens are set in such a manner as to provide a three-dimensional

view of the computer-generated environments. A tracker on the

top of the HMD signals to the computer the precise location of

the patient’s head. The computer gives the patient a different

view of the environment with every head movement and everytime

he squeezes the button on the joystick in the landing zone.

Dr. Ready demonstrates how to monitor movement

within Vietnam virtual reality and talk to patient, with

social worker Kevin Wilson, volunteering to wear HMD.

\
	

		





	
	
		 	


There is more evidence for exposure therapy than for

any other intervention for PTSD (5). Yet, it has been greatly

underutilized with US combat veterans (6). This underutilization

may partly be due to the difficulty of doing imaginal exposure

with this patient population and the impracticality of providing

in vivo exposure. Many veterans find it very difficult to stick

with their traumatic memories long enough to allow habitation

in imaginal exposure. With combat-related trauma it would be

very expensive and possibly dangerous to provide actual machine

gun fire, mortars, and helicopters for in vivo exposure.

The patient is informed that he is

to have one foot in Vietnam and

one foot in the lab. It is this

balance of the traumatic memory

being stimulated by the VR yet

maintaining constant contact

with the therapist that facilitates

emotional processing.

Virtual Reality opens up the possibility of providing

exposure that is in near vivo quality without the potential hazards

and inconvenience of real in vivo exposure. Within the VR

environment the therapist has

complete control over everything

that the patient sees and hears in

terms of both the presence and the

intensity of stimuli. For example,

stimuli such as mortars can be

turned on and off and the intensity

of the mortars can be modified by

both the frequency that the mortars

are dropped and by the volume of

the explosions. When the volume

is lowered the mortars sound as if

they are landing farther away,

making them seem less dangerous

to the patient.

There are three phases of treatment. The first phase

includes the initial evaluation and the first session. During

this phase patients are carefully screened to determine if

they meet the inclusion criteria (Vietnam veterans who suffer

from PTSD) and do not meet the exclusion criterion (history

of psychosis, current or recent substance abuse, bipolar

disorder or lack of a support system, or a medical

contraindication such as a heart condition). This is

accomplished through a clinical interview and assessment

battery, which includes the Clinician Administered PTSD

Scale (CAPS) (7). Patients are asked to provide a copy of

their military discharge summaries (DD214) and submit to

a drug screen. The patient’s current mental health team is

contacted to get input before deciding to offer VR exposure

to a patient. At this time the treatment is explained to the

patient in detail. It is very important that the patient is

well informed about the rationale and procedures of the

treatment. A failure here may make it much more likely

that the patient will terminate treatment prematurely. A

patient must clearly understand the nature of the treatment

and signthe informed consent before beginning treatment.

 During the first session the procedures and rationale

of treatment are reviewed and the patient is exposed to a neutral

VR environment. This is a virtual room in which he can move

with no threat cues to get him used to VR, and to teach him

how to navigate within a VR environment.

During the second phase the patient is oriented to the

Virtual Vietnam environment that will be used in his treatment.

If his trauma is mainly related to helicopters, then the helicopter

environment is used. If his trauma is mainly related to ground

combat, then the landing zone environment is used. This phase

can take from two to five sessions depending on the patient’s

response. The goal here is to get the patient familiar with the

environment and have him build up some tolerance to the

listening. The typical session takes about 90 minutes. The first

15 minutes are spent assessing the patient’s current state of

mind, checking on homework, asking about his reaction to the

treatment and negotiating what will occur in the VR.

Occasionally, the therapist and patient may decide not to conduct

VR exposure therapy during a session as when a patient had

been in an auto accident the day before. On those occasions a

more traditional, non-VR psychotherapy session takes place to

deal with any issues that have arisen. In the VR treatment the

patient sits in a special chair (with a large woofer in the bottom

to create vibrations) for the helicopter environment or stands

up on a platform that has rails around it (to keep the patient

within range of the computer’s tracker) for the landing zone

environment. He then dons the HMD (described above). The

therapist communicates with the patient through a microphone

that is patched into one of the patient’s earphones. The VR

exposure lasts 30 to 45 minutes, depending on how the patient

is responding. While in VR the patient is asked for a Subjective

Units of Discomfort Scale (SUDS) rating (0-100) every 5

minutes. This rating helps monitor how the patientis responding

to the VR exposure and assists in determining when to add new

stimuli. The therapist is in frequent contact with the patient by

stimuli that will be used when he

confronts his traumatic combat

memories in the next phase of

treatment. During all exposure

sessions an audiocassette recording

is made of the exposure portion of

the session. The patient is

instructed to listen to this tape daily

between sessions. This increases

the amount of exposure the patient

experiences and often gives him a

sense that he is moving forward as

the same exposure has less and less

effect on him with repeated
	

		





and now. The patient is informed that he is to have one foot in

Vietnam and one foot in the lab. It is this balance of the

traumatic memory being stimulated by the VR yet maintaining

constant contact with the therapist that facilitates emotional

processing.

One of the common signs that the memory has been

accessed is the presence of body memories. The term “body

memories” refers to the physical sensations related to the

traumatic memory but that are inconsistent with the present

environment. Common examples include the patient feeling

very hot and sweating (as he did in Vietnam) or feeling pain

where he was wounded. These sensations often dissipate

quickly once the patient leaves the VR environment. Body

memories are often strongest during the first five or so sessions.

Having fewer and less intense body memories is usually a

sign that the patient is successfully processing the memories.

During this phase the patient will usually start with

a story that is somewhat limited. As the sessions progress

more details will emerge. As these additional details emerge,

the story often makes more and more sense to the patient

and he often feels less and less anxiety about what he recalls.

In addition, the patient’s SUDS ratings tend to decrease in

response to the same stimuli over time, indicating habituation.

Patients often report that a traumatic memory that has haunted

them for over thirty years no longer comes to mind as

frequently and when it does, has much less impact. It is as if

a terrible experience that happened recently (although it was

over three decades ago) has shifted into a sad event that

happened a long time ago.

Currently a total of 21 patients have started VR based

exposure therapy and 15 have completed it. Most patients

can complete VR treatment within 15 sessions. All six of the

dropouts were within the first year of our developing this

new treatment and none reported any lasting negative effects.

Four of the dropouts reported that the VR was too

stimulating, two of these within the first twenty minutes of

virtual Vietnam exposure. The others indicated that they did

not feel the therapy was helping them. Nine of the last nine

patients who have started VR exposure treatment completed

it. A clinical interview and assessment battery was administered

prior to treatment, at the completion of treatment, and three

and six months after treatment. Clinically and statistically

significant PTSD symptom reductions were found on the

Total CAPS scores on all three post-treatment assessments.

On the re-experiencing subscale of the CAPS statistically

significant decreases in symptoms were found when the three

and six month follow-up assessments were compared to the

pre-treatment scores. In both the avoidance subscale and

the hyperarousal subscales of the CAPS there were significant

decreases in symptoms on all three post treatment

	


	

requesting clarification about what the patient is describing or

asking about body sensations that relate to stress or trauma.

This careful monitoring helps determine when to add, intensify,

lessen or remove stimuli. At the end of the VR exposure the

patient removes the HMD and material that arose in the session

is discussed.

Once it is clear that the patient is able to tolerate the

VR stimuli that relate to his trauma the third phase begins,

focusing on the patient’s most traumatic Vietnam memories.

The patient is asked to describe, in detail, the traumatic

experience as it unfolded and to talk about it in the present

tense (“I see the enemy approaching”). The therapist turns

on and off visual and audio effects in sequence with what the

patient describes. For example, when a patient indicates that

he hears enemy machine gun fire the therapist activates

machine gun fire until the patient indicates the firing stopped.

Of course, it is impossible to duplicate all of the sights and

sounds of war in a VR environment. However, we have found

that providing some of the key elements, such as gunfire,

explosions and helicopters, is enough to assist the patient in

getting in touch with and staying with the traumatic memories.

Often patients report seeing, smelling or hearing things that are

not in the virtual environment. This projection indicates that

they are very engaged with the traumatic experience. This is a

good sign as long as the patient does not dissociate and stop

responding to the therapist. This is a rare event but if it happens

the therapist quickly reestablishes the connection with the

patient, which sometimes requires lowering the intensity of the

VR stimuli.

The primary role of the therapist during VR exposure

therapy is to provide enough of the appropriate stimuli at

the right time and at the level of intensity that can be tolerated

by the patient while assisting in therapeutic exposure. This

can only be accomplished by a careful moment-by-moment

monitoring of the patient’s responses to the stimuli and

attention to the patient’s recounting of the traumatic memory.

With the right titration the patient will be greatly aided in

accessing his fear structure without becoming overwhelmed

by the VR environment (8). The therapist needs to consider

both the effect of the stimuli that he/she is providing and to

what degree the patient is responding to the internal stimuli

of his traumatic memory. If the patient is not responding to

this internal stimuli at all then he is not accessing the traumatic

memory and it is unlikely that change will occur. On the

other hand, if the patient is so in touch with these stimuli

that he is no longer responding to the therapist then it is unlikely

that any therapeutic processing of the traumatic memory will

take place. If the patient seems to be overresponding to his

internal stimuli the therapist reduces the external stimuli and

insists that the patient respond to the therapist in the here
	

		





assessments. This preliminary evidence suggests that this

treatment can reduce PTSD symptoms and that these reductions

can be maintained over time (9).

 The most challenging part of exploring this new type of

exposure therapy has been patient recruitment. Many

patients are reluctant to be among the first to try a new

treatment and many are afraid of exposure therapy. It also

took time to refine our procedures. All of the patient responses

to VR exposures have been very manageable on an outpatient

basis.

The biggest challenge that the field of VR exposure

therapy faces is the initial expense of creating VR

environments. Most environments are PC-based and the

additional equipment necessary to run a VR environment is

not prohibitively expensive.

The following has been made clear by the work

accomplished thus far. (I) VR can produce an intense sense

of being in a similar environment to that in which combatrelated trauma took place in Vietnam veterans. (II) Patients

can have this sense and still maintain awareness that they

are in a therapy session, which helps them to not become

overwhelmed by the stimuli in the VR environment. (III)

Emotional processing can occur as a result of VR based

imaginal exposure. (IV) This processing can lead to significant

symptom reduction; and finally (V) the positive effects of

this treatment can last over time. We believe that Virtual

Reality can be a powerful new tool in exposure therapy and

can be a component of a comprehensive treatment program

for Vietnam veterans suffering from PTSD.

Future applications of Virtual Reality are limited less by

the technology than by the imagination of those who wish

to utilize it. The next logical step will be to test this

application in a controlled study.

Case example

Mr. D is 100 percent service connected for PTSD

and served in Vietnam for only three weeks before being

medically evacuated. The twelve VRE sessions focused upon

an incident in which he was severely wounded and trapped

between US and NVA forces after the truck he was driving

was blown up. As Mr. D described being caught in the

crossfire, enemy machine gun fire, rocket explosions, mortar

explosions, screaming, and battle ambience (a firefight in

the distance) were activated in response to different parts of

his story. When he described the enemy withdrawal the

volume for these effects was reduced until they faded away.

A helicopter landing and taking off was used to simulate his

being flown to a field hospital. Mr. D’s overall CAPS score

was 51 percent lower on his immediate posttest and these changes

were maintained on his three-month follow-up assessment

References

1. Van Etten, M.L., & Taylor, S. (1998) Comparative efficacy

of treatment for post-traumatic stress disorder: A metaanalysis. Clinical Psychology and Psychotherapy, 5, 126-

144.

2. Foa, E.B., & Kozak, M.J. (1986). Emotional processing of

fear: Exposure to corrective information. Psychological

Bulletin, 99, 20-35.

3. Rothbaum, B.O., Hodges, L.F., Kooper, R., Opdyke, D.,

Williford, J.S., & North, M. (1995). Effectiveness of

computer-generated (virtual reality) graded exposure

in the treatment of acrophobia. American Journal of

Psychiatry, 152, 626-628.

4. Anderson, P.L., Rothbaum, B.O., & Hodges, L. (2001).

Virtual reality: Using the virtual world to improve quality

of life in the real world. Bulletin of the Menninger Clinic

Supplement, 65, 4-17.

5. Rothbaum, B.O., Meadows, E.A., Resick, P., Foy, D.W.

(2000). Cognitive-behavioral therapy. In E.B. Foa, T.M.

Keane, et al., (eds.), Effective treatments for PTSD:

Practice guidelines from the International Society for

Traumatic Stress Studies (pp. 60-83). New York:

Guilford.

6. Boudewyns, P.A. (1994). Direct therapeutic exposure: A

learning-theory-based approach to the treatment of

PTSD. In L. Hyer & Associates (eds.), Trauma victim:

Theoretical issues and practical suggestions. Accelerated

Development, Muncie, Indiana.

7. Blake, D.D., Weathers, F., Nagy, L.M., Kaloupek, D.G.,

Klauminzer, G., Charney, D.S., & Keane, T.M. (1992)

A clinician rating scale for assessing current and lifetime

PTSD: The CAPS-1. The Behavior Therapist, 13, 187-

188.

There were reductions in all three symptoms clusters. There was

an increase in arousal and avoidance symptoms on the six-month

follow-up assessment. These changes may have been the result

of his relocating across the country due to his wife’s job transfer

and the resulting disruption in his regular PTSD treatment.

The overall score on the six month post treatment CAPS was

31 percent lower than his pretreatment score.

	
	
		 	

	

		





8. Foa, E.B., Steketee, G., & Rothbaum, B.O. (1989).

Behavioral/cognitive conceptualization of posttraumatic

stress disorder. Behavior Therapy, 20, 155-176.

9. 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.

.

Larry F. Hodges is Associate Professor and Head of the Virtual Environments Group in the Graphics,Visualization and Usability Center

at Georgia Tech. He is currently a Senior Editor for the journal Presence: Virtual Environments and Teleoperators and a member of the

IEEE Computer Society’s Executive Committee for Visualization and

Computer Graphics.

David J. Ready is the clinical psychologist for the Atlanta

VAMC’s Posttraumatic Stress Disorder Clinical Team (PCT).

He was the primary therapist in the first use of Virtual Reality

to treat PTSD and is an Assistant Professor, Clinical Track in

the Department of Psychiatry & Behavioral Sciences of Emory

University School of Medicine.

Barbara O. Rothbaum, Ph.D. is an associate professor in

psychiatry at the Emory School of Medicine in the

Department of Psychiatry & Behavioral Sciences and director

of the Trauma and Anxiety Recovery Program at Emory.

Dr. Rothbaum specializes in research on the treatment of

individuals with anxiety disorders, particularly focusing on

PTSD, and has published two books on the treatment of

PTSD. Drs. Rothbaum and Hodges are pioneers in the

application of virtual reality to the treatment of

psychological disorders.

	
	
		 	


Acknowledgments: This research was supported by NIMH

grant # 5 R21 MH55555-02 awarded to Barbara

Rothbaum. The authors would like to thank Renato D.

Alarcon, Ken Graap, Stacey Pollack, Greg Inman and Fran

Shahar for their invaluable contribution to this project.

Disclosure statement: Drs. Rothbaum and Hodges are

entitled to sales royalties from Virtually Better, Inc., which

is developing products related to this research. In addition,

they serve as consultants to and own equity in Virtually

Better, Inc. The terms of this arrangement have been

reviewed and approved by Emory University and Georgia

Institute of Technology in accordance with their conflict

of interest policies.
	

		

 



NATIONAL CENTER FOR PT TIONAL CENTER FOR PTSD

EDUCATION, TRAINING,

 & SUPPORT SERVICES

The Education and Clinical Laboratory Division for the National Center for Post Traumatic Stress Disorder at the

Palo Alto CA VAMC, in collaboration with the VA Employee Education System, offers a Clinical Training Program

(CTP). The training program is approved for 30 Category 1 CEUs for physicians, psychologists, social workers,

and nurses. The CTP offers a broad range of educational activities, including:

* Lectures

* Clinical consultation

* Clinical observation of group treatment

* Group discussions facilitated by staff

Specific training topics include warzone trauma group treatment, treatment of women veterans, treatment of

sexual assault related PTSD, relapse prevention, cross cultural treatment issues, assessment and treatment of families,

disaster mental health services, cognition and PTSD, assessment of PTSD, and psychiatric assessment.

Week long training programs are scheduled nine times per year, on the second or third week of the month. Funding

for attendance is not available from the National Center. There is no fee for the training program itself, but

participants are responsible for providing their own transportation, lodging, and meals. Interested applicants are

encouraged to explore funding options through their local medical centers or VA Employee Education System.

For more information, or to request an application, please email:

	



	

	

	
	





	








	
	
	
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Josef.Ruzek@med.va.gov or telephone 650-493-5000, ext. 22673.
	

		

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