ART an Example

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Voice Over:

Hello, I’m Dr. David Stone, a therapist who uses Prolonged Exposure Therapy to treat victims of PTSD. Many of my clients are veterans who have suffered trauma and loss in combat. Prolonged Exposure Therapy often includes the use of pictures or other materials to help the patient recall and re-experience the traumatic events that are the focus of therapy.

Today therapists have the advantage of replacing these static materials with dynamic and immersive augmented reality environments that can be customized to reflect the actual experiences of the patient in any environment. Under the control of the therapist, these immersive environments can include locations, interactive objects (cars that one can drive) and people (photorealistic robots) who can be made to say whatever the therapist directs in an interactive manner. The therapist can determine the degree of realism desired each time the environment is used.

These environments offer a degree of immersion and realism that have, up to this time, been extremely difficult and expensive to achieve. Today, we can provide these environments on standard, inexpensive computers without the need for expensive special equipment. With proper safeguards, we can even make it possible for the therapist to work with patients remotely so that they can remain in the comfort of their own homes.

To show you how these environments may be used, I have prepared the following storyboard that was used to support Prolonged Exposure Therapy with a recent client. The client had served in the U.S. Army in Iraq. The therapist sought to replicate the experience of the patient in a combat situation.

 

Iraq Scenario

Simulation of being a “first responder” to a Iraqi police station that has been attacked:

“My patient was Sgt. Jack Stone on who was on patrol with his team in two vehicles in Iraq just prior to the traumatic event. While on patrol he received a report of an attack on an Iraqi police station that included casualties and damage. Sgt. Stone’s mission was to secure the area, assist the wounded and provide an analysis of the incident.

Sgt. Stone was in the second vehicle of the two vehicles on pratrol that approached the burning police station. Sgt. Stone watched as an Apache helicopter hovered near the site to provide reconnaissance information and, if needed, suppressive fire power*.”

As the first vehicle in his team approached the police station it hit an IED that injured some and killed one of his team members and damaged the vehicle. Sgt. Stone approached the first vehicle following its tracks to ensure his safety and to offer immediate medical assistance to the injured calling for medical evacuation of those injured.


Sgt. Stone provided immediate first aid to the injured and pulled the dead body of Specialist James Wilson from the burning vehicle. The report of the incident provided by the Army made it clear why Sgt. Stone was decorated for his action in this incident. He risked his life in saving the injured and barely escaped death when the vehicle exploded.

Despite his courage and the medal he received for his actions, Sgt. Stone continued to relive this traumatic event long after his return home from Iraq. He could not stop thinking about it and he was troubled by dreams in which he repeatedly failed to save his friend’s life.His wife reported that he had trouble sleeping, was given to bursts of anger without apparent reason and had become increasingly isolated from family and friends.

Overview
Post-traumatic stress disorder is a type of anxiety disorder. It can occur after
the patient has seen or experienced a traumatic event that involved the
threat of injury or death.

Symptoms
Symptoms of PTSD fall into three main categories:

  1. Repeated “reliving” of the event, which disturbs day-to-day activity
    • Flashback episodes, where the event seems to be happening again and again
    • Recurrent distressing memories of the event
    • Repeated dreams of the event
    • Physical reactions to situations that remind you of the traumatic event
  2. Avoidance
    • Emotional “numbing,” or feeling as though the patient doesn’t care about anything
    • Feelings of detachment
    • Inability to remember important aspects of the trauma
    • Lack of interest in normal activities
    • Less expression of moods
    • Staying away from places, people, or objects that remind the patient of the event
    • Sense of having no future
  3. Arousal
    • Difficulty concentrating
    • Exaggerated response to things that startle the patient
    • Excess awareness (hypervigilance)
    • Irritability or outbursts of anger
    • Sleeping difficulties

The patient also might feel a sense of guilt about the event (including “survivor guilt”), and the following symptoms, which are typical of anxiety, stress, and tension:

  • Agitation, or excitability
  • Dizziness
  • Fainting
  • Feeling his heart beat in his chest (palpitations)
  • Fever
  • Headache
  • Paleness

Sgt. Stone exhibited most of these symptoms prior to and during the initial phases of treatment. The therapist correctly diagnosed his condition as PTSD. The Treatment Plan called for reducing symptoms by encouraging Sgt. Smith to recall the event, express his feelings, and gain some sense of control over the experience. For Sgt. Smith who had lost a close friend in this incident there were intense feelings of guilt since he had been the leader responsible for the teams actions along with profound grief at his loss.Prolonged Exposure Therapy was also included in the treatment. Years of research have established the value of prolonged exposure therapy as a tool to help patients overcome trauma of various kinds. Prolonged Exposure Therapy is a form of Cognitive-Behavioral Therapy. This approach requires that the patient tell and retell the story of the trauma again and again. This retelling of the story of the trauma is called habituation. The retelling eventually removes the enormous power of cues that trigger the memory to provoke reactions to the memory. Eventually the cues lose their power to provoke extreme reactions. The trauma is reduced to a single event in memory and not the continuing source of stress. It is no longer a “condition”.Over the course of many weeks Sgt. Stone returned to my office for treatment. During the third week of treatment I introduced Sgt. Stone to the Augmented Reality Environment. He told me that he thought the recreation of the environment was realistic, but that it helped that we were using computer graphics rather than video so that he could be “immersed” in the environment, but still remember he was still safe in my office.

At first we focused on just getting used to being in the augmented reality version of Iraq. I used relaxation exercises to help him learn to “be there” without experiencing the stress and anxiety that his memories had so often triggered in everyday life.

Gradually, over time, I introduced elements of the patrol that he remembered so painfully. With each step we worked on relaxation, stress reduction and discussion of his thoughts and feelings.
In time, Sgt. Stone was able to experience the simulation right up to the point of the IED explosion without the severe anxiety and stress he initially experienced just from memory.

In time, we were able to recreate and experience the entire experience, talking through his feelings and helping him overcome his guilt and grief. Eventually he and his wife reported that the nightmares ended and that he was losing the “numbness” and isolation he had experience for so long.

Sgt. Stone’s experience is typical and while this example has focused on a military example. Augmented Reality Therapy can be used with other types of clients who suffer from the debilitating effects of trauma.

Prolonged Exposure Therapy Protocol

Standard

Prolonged Exposure Therapy Protocol

Years of research have established the value of prolonged exposure therapy as a tool to help patients overcome trauma of various kinds
Prolonged exposure therapy is sometimes called “Immersion Therapy”, a term suitable for the Virtual Reality environment.
Prolonged Exposure Therapy is a form of Cognitive-Behavioral
Therapy. This approach requires that the patient tell and retell the story of the trauma again and again.
This retelling of the story of the trauma is called habituation. The retelling eventually removes the enormous power of cues that trigger the memory to provoke reactions to the memory. Eventually the cues lose their power to provoke extreme reactions. The trauma is reduced to a single event in memory and not the continuing source of stress. It is no longer a “condition”. It is a widely used approach, for example, being used at Cornell University’s Medical Center in New York with September 11 survivors.

Dr. Stone uses Prolonged Exposure Therapy with victims of PTSD follows the research protocols used in various research projects and published in refereed journals.
In the first session the patient is oriented to the virtual reality environment, gets an avatar and gets to look around the virtual environment created for his condition.
Subsequent session add additional realism so as to reflect the actual environment the patient encountered during the trauma.
In combination with established relaxation and stress reduction tools long used in psychotherapy patient learn to relaxin the presence of the cues that have been the source of the stress disorder.
The combination of relaxation and prolonged exposure robs the cues of their power in time.
Dr. Stone is available to provide training in the clinical application of this approach should that be desired
Dr. Stone is a TRICARE “in network” provider, served as a Major in the Army Medical Service Corps and has recent training in working with victims of PTSD.
He is licensed in both New York State and Georgia.

Prolonged exposure therapy is sometimes called “Immersion Therapy”, a term suitable for the Virtual Reality environment.