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  The focus of the 306th’s mission was “detention operations.” Della Salla and his fellow soldiers were in charge of Camp Redemption, a large internment center filled with tents that held twenty-five prisoners each. For fourteen hours a day, the soldiers acted, Della Salla says, like “den mothers,” dispensing meals and providing health care. Each soldier generally ran two tents, where he or she interacted with the tent chiefs (primarily imams, or religious leaders), who dispensed the soldier’s orders to their tent mates. As a result of the prisoner abuse scandal, the detainees’ rights were listed on cards that the soldiers carried at all times. Still, riots inside the tents constantly occurred. For Della Salla, the stress of his work as a “zone dog,” combined with the continual insurgent attacks on the base, was nearly unbearable.

  Whenever the prison itself became too crowded, Della Salla’s unit received orders to “decongest” it, which involved transferring prisoners to other locations. These so-called ConAir operations included running high-risk convoys to the nearest airstrip. Despite the inherent danger, Della Salla found himself wishing daily for one of these missions, because they allowed him to escape the pressure-cooker atmosphere of the base. Anything was better than managing the tents.

  One night Della Salla had just finished dinner when he struck up a conversation outside the soldiers’ living area with an NCO named Caruso. As they talked, Caruso’s face abruptly turned red. Della Salla had his back to the base’s walls; it took him a moment to grasp what Caruso was looking at. As he did, Caruso screamed “Incoming!” and grabbed Della Salla and threw him into the living area. At that moment—just after 7 p.m. Baghdad time—a barrage of mortar and rocket fire came streaming over the base’s walls. So began the worst three hours of Della Salla’s deployment.

  Now known as the Battle of Abu Ghraib, the night of April 2, 2005, represented an enormous, highly coordinated insurgent assault on American forces at the base. Small arms, grenades, and even two vehicle-borne IEDs were part of the attack. At the same time, the airstrips in Camp Victory and Fallujah were paralyzed by enemy shelling. A full hour passed before Della Salla’s unit and the other battalions at Abu Ghraib received close air support. The insurgents had mined the roads to the west and east, effectively blocking any attempts to send additional ground troops and supplies to support the soldiers on the base. Supplies dipped so low that U.S. forces received orders to fix bayonets for probable hand-to-hand combat.

  As the hours ticked by, Della Salla’s unit struggled to maintain control over the thousands of prisoners in Camp Redemption. Della Salla also ran medical supplies through an outside quad, where he could hear the enemy rounds getting louder and louder as the insurgents, adjusting their fire, moved ever closer to the base. (The increasing volume of the rounds is a memory that haunts him still.) At one point Della Salla was moving through the quad when a rocket-propelled grenade landed about one hundred yards away, just on the other side of the Jersey barrier, the huge cement slab that marked the outside wall. Though the barrier saved Della Salla’s life, the shock waves of the RPG sent him sprawling to the ground. He felt as if a linebacker had tackled him. Still, his adrenaline was running so high that hours passed before he realized he’d been injured by the blast. He was one of dozens of American troops wounded in the battle.

  After three hours of heavy fighting, the insurgents finally ended their assault. But any sense of security Della Salla had felt on the base was gone for good.

  When he returned to the States after his tour in Iraq, Della Salla moved to the 78th Training Support Division, the unit he had trained under when he was with the MPs. At home he started fighting with his family and friends, and he felt riddled with anxiety, though it took him some time to grasp this, because he had spent the past twelve months in such a state of high tension.

  Whenever Della Salla had to report to work with his new unit, he would get in his car and drive from New York City to Secaucus, New Jersey. As he traveled along the highways and beneath the overpasses, his heart would begin to race, he would grow short of breath, and he would find himself gripped by the overpowering fear that he was trapped. Eventually he would become so lightheaded that he’d have to pull to the side of the road until the worst of the symptoms had passed. These panic attacks confused him. He knew he was driving in a car, not in a fortified Humvee, and that he was in New Jersey, not in some convoy on the jam-packed roads outside Baghdad. But this awareness made little difference. Particular triggers—a stretch of highway, an overpass—would set him reeling every time.

  Several months after his return, Della Salla began seeing a therapist named Michael Kramer at the VA hospital in Manhattan. At first he and Kramer followed the traditional therapy model: they sat and talked. With Kramer’s guidance, Della Salla described his upbringing, his relationships with his family and friends, his experiences at Abu Ghraib, his difficulty in adjusting to life back in the States, and the memories of Iraq that continued to haunt him. He felt the sessions were useful; he had a number of issues that Kramer helped him to express and analyze. At the same time, he continued to feel overwhelming fear, anxiety, and helplessness. He felt powerless to control what he and Kramer had identified as post-traumatic stress disorder.

  In 2007, about a year after their first meeting, Kramer asked Della Salla if he would like to try a new program called Virtual Iraq as part of his treatment. The program combined a virtual-reality/video game component with traditional exposure therapy. Though he trusted Kramer, Della Salla was initially reluctant. “This can’t work,” he told Kramer. “It’s a video game. If I want to use anything virtual, I might as well go to the actual videos I shot in Iraq. That’s real shit.”

  Still, Della Salla’s curiosity eventually got the better of him, and he agreed to become the first person from the Manhattan VA hospital to use Virtual Iraq. (Kramer, for his part, had been battling the VA bureaucracy to get them to fund the program.) In so doing, Della Salla became one of thirty-five initial active-duty soldiers and veterans to experience what may be the most promising new method for treating psychological trauma.

  Virtual-Reality Exposure Therapy

  Now operating at dozens of sites across the country, Virtual Iraq and its more recent counterpart, Virtual Afghanistan, are the most widely used virtual-reality exposure therapy (VRET) treatment programs in America. The treatment is a variation on traditional exposure therapy, which itself derives from classic conditioning, in the manner of Pavlov and his dogs. The idea is that by reenacting a traumatic experience or confronting an irrational fear under controlled conditions and then by gradually increasing the intensity of the experience in the context of a safe, therapeutic environment, a patient will become habituated to that experience or fear. The trauma will not disappear, but it will become manageable.

  Exposure therapy has a long track record of success in helping people deal with phobias, but it can be prohibitively expensive or even dangerous to conduct on-site. The standard practice, then, is imaginal exposure therapy, in which a therapist repeatedly guides the patient through an imaginary reconstruction of the feared experience. However, this technique demands that the traumatized person vividly recall terrifying experiences, something that PTSD sufferers, given the nature of their condition, are often unable or unwilling to do.

  Virtual-reality exposure therapy, made possible by recent technical advances in computing speed, graphics rendering, artificial intelligence, and tracking and interface technology, is a potential solution to those problems. Wearing a head-mounted display (a helmet with goggles and earphones), patients are placed in immersive interactive environments designed to represent their traumatic memories, ensuring that they can confront their experiences without having to conjure up the memories themselves. Since its origins in the early 1990s, virtual-reality exposure therapy has proven remarkably effective at treating anxiety disorders; initial studies indicate a cure rate of between 70 and 90 percent. The Department of Defense has been the largest funder of research, with Virtual Iraq/Afghan
istan almost solely responsible for bringing this form of therapy to the attention of the larger psychiatric community. If we ask what effects the military’s use of video games will have on society at large, one of the areas of greatest influence will be in the field of mental health. In this sense, the most important video game–related legacy of these wars may have nothing to do with preparing for war at all but be concerned with treating war’s aftermath.

  With Virtual Iraq, patients are immersed in a variety of settings and scenarios taken from the military-funded commercial video game Full Spectrum Warrior. It includes a twenty-four-block city scenario, which features both crowded and desolate streets, a marketplace, empty lots, checkpoints, vehicles (parked and moving), mosques, and a variety of buildings. Users can walk the streets alone or accompanied by computer-animated soldiers; they can enter buildings or climb onto rooftops. It also includes a desert road scenario in which users ride in a Humvee past other vehicles, checkpoints, debris and wreckage, and buildings in various states of disrepair. Users can sit in various parts of the cab or in the exposed turret, as gunners do. (Virtual Afghanistan has its own set of backgrounds, buildings, and other relevant details.) When I tried Virtual Iraq, I was struck by how intense the experience was, though not because of the graphics per se. Yes, the program looked like a video game, but the head-mounted display and other supporting elements combined to make it an unnervingly vivid environment.

  A typical course of treatment with Virtual Iraq/Afghanistan consists of ten fifty-minute sessions. The first session includes an intake interview and an overview of the program; the second session includes education about exposure therapy in general and the Subjective Units of Distress Scale (SUDS), which the patient uses to communicate his current level of discomfort to the clinician. The patient then engages in imaginal exposure therapy. During the third session, the patient experiences the virtual world without recounting his traumatic experiences. In the following six sessions, the patient re-creates his traumatic experience while in the virtual world, narrating it with increasing detail and intensity.

  Using a so-called Wizard of Oz control pad, clinicians can select the setting for the virtual experience and customize the atmospheric conditions, time of day (night vision is available), ambient sound (such as traffic, wind, or a call to prayer), and even scents (burning rubber, garbage, body odor, cooking spices, gunpowder). They can also introduce IEDs, car bombs, and gunfire. The goal is to re-create the patient’s original traumatic experience and then gradually ratchet up the intensity. The scenario doesn’t have to match the original experience; it simply has to include similar stressors, such as an exploding IED or a crowd of hostile strangers. Patients control their virtual behavior by manipulating a simulated M4 gun. The weapon cannot be fired; it is intended solely as a mood-setting device.

  Throughout a given session, clinicians are in constant contact with the patient, and they can view what the patient is experiencing on their control screens. On the basis of the patient’s self-reported SUDS score and the physiological data available (heart rate, galvanic skin response, respiration), clinicians can determine how fast or slow to go. They also ask questions, prompt feedback, and offer support during stressful periods. Each individual session, and the course of treatment as a whole, unfolds at the patient’s pace.

  Origins of the Game

  Virtual Iraq/Afghanistan is the brainchild of Dr. Albert “Skip” Rizzo, a clinical psychologist and associate director for medical virtual reality at the army-funded, USC-affiliated Institute for Creative Technologies in Los Angeles (the original game institute founded by Mike Zyda). Along with his Virtual Iraq/Afghanistan colleagues Barbara Rothbaum, a professor of psychiatry at Emory University, and JoAnn DiFede, director of the Program for Anxiety and Traumatic Stress Studies at Weill Cornell Medical College, Rizzo is one of a small but increasingly influential group of researchers working in the discipline of virtual-reality exposure therapy.

  Rizzo presents a striking contrast to many of his military and civilian counterparts. A long-haired, motorcycle-riding, foulmouthed, friendly bear of a man, he prefers leather jackets, jeans, and Harley-Davidson T-shirts to his male colleagues’ wardrobes of button-down shirts and khaki pants. He is a passionate rugby player, and his nose, as The New Yorker’s Sue Halpern once wrote, “looks like it has met a boot or two.” That face is frequently wreathed in cigarette smoke from one of his many daily Marlboros, a habit he picked up, ironically enough, when he ran an antismoking clinic early in his career. Yet beneath his rough surface and laid-back attitude lies a compassionate, driven man who has dedicated his career thus far (he is in his late fifties) to treating traumatic brain injuries and placing new technologies at the service of behavioral health care.

  The origins of Virtual Iraq/Afghanistan can be traced to the early 1990s, when Rizzo worked as a cognitive-rehabilitation therapist at a hospital in Costa Mesa, California. Because of his focus on traumatic brain injuries, most of his patients were young men, the population most associated with high-risk behaviors, whether driving drunk or being members of a gang. Patients would come in four times a week for four-hour sessions; during breaks, they would wander outside and rest on the lawn. Rizzo noticed that one of his patients, Tim, a man of about twenty, would spend his breaks sitting under a tree, intently playing with a handheld device that Rizzo had never seen before. One day he asked Tim what he was doing. “And he showed me this Game Boy—it’s a new thing, Game Boy,” Rizzo says, “and he’s playing Tetris. And I watched him play, and he was like a friggin’ Tetris warlord. Here’s a kid that was very difficult to motivate for more than ten or fifteen minutes on any one particular cognitive retraining exercise, but here he was, focused and working and getting better at [the game].” Soon it seemed to Rizzo as if all his young male patients were playing on Game Boys on their breaks.

  The experience was an eye-opener. Rizzo had been using Apple II-E software for cognitive training, but the software was primitive and not particularly engaging for patients. He felt that computer-based approaches offered a great deal of potential for his work, but it wasn’t until he saw those approaches in a gaming context that he realized how that potential might be fulfilled.

  Not long afterward, Rizzo got a Nintendo NES loaded with SimCity. He became fascinated by the game, and he realized that SimCity highlighted everything clinicians refer to as “executive functioning,” which refers to the integration of all one’s cognitive functions for goal-directed behavior. Aside from learning the interface, players were required to develop and implement a strategy, monitor their performance, and revise and update that strategy—“all the kinds of things the brain typically does in complex everyday situations,” Rizzo says. He took SimCity in to his patients, and they loved it; they spent hours focused on their game play.

  While Rizzo was becoming interested in gaming, virtual reality was seeping into the public consciousness. He began to consider returning to academia, where he could chart a path for harnessing these new technologies in the service of clinical practice. He was not by nature a technological person, but he saw how virtual reality and gaming could be an ideal match for exposure therapy. “That was a no-brainer right out of the gate,” he says. In 1995 he took a postdoctoral position at USC’s Alzheimer Disease Research Center, where he drew on his years of clinical experience with Alzheimer’s patients and patients with traumatic brain injuries. Still, he admits, “the real mission was to make friends with the folks who were in computer science and get access to a foothold.”

  Over the next several years, Rizzo poured himself into designing virtual-reality systems that could be used in clinical settings. After his postdoctoral work, he took a position at USC’s Integrated Media Systems Center, where he and a programmer began running studies involving virtual reality.

  Rizzo was still working at the center in March 2003, when the United States invaded Iraq. “I’m watching all this stuff, ‘mission accomplished,’ all this horseshit,” he says, “and I’m thinking, Y
ou know, they’re talking about nation building—this isn’t going to be a cakewalk.” He realized that the war would probably produce a generation of traumatized veterans. To avoid another post-Vietnam situation, he believed the health-care profession needed to work quickly on finding effective and accessible treatments for PTSD.

  While preparing for a talk on the subject, Rizzo visited the website for the Institute of Creative Technologies to see if he could find any relevant material. There he found a clip of the institute’s newly developed video game Full Spectrum Warrior.* “When I saw [the game],” Rizzo says, “it looked just like Iraq. In my mind, anyway—I’d never been to Iraq. But it had that Middle Eastern look to it. And I thought, Why can’t we just take this content and modify it and make it into a therapy tool?”

  Rizzo contacted Jarrell Pair, an ICT researcher who in 1997 had programmed Virtual Vietnam, the first virtual-reality application for PTSD. Developed by researchers in Atlanta, Virtual Vietnam immersed users in one of two settings, a jungle clearing or a Huey helicopter, with a limited number of customizable details. Though the graphics were crude, the program seemed effective. A case study of a fifty-year-old veteran with treatment-resistant PTSD yielded promising results, as did a subsequent small-sample controlled study. But the results were never followed up, and the project soon came to an end.

  Rizzo and Pair began working on a prototype of Virtual Iraq, which they finished in early 2004 and which used graphics from Full Spectrum Warrior to depict an Iraqi market street. When Rizzo applied for money to develop the project further, however, he was turned down. He continued to knock on doors until July, when the New England Journal of Medicine published a paper by epidemiological researcher Charles Hoge and his colleagues at Walter Reed Military Medical Center. The article outlined for the first time the high incidence of PTSD among soldiers in Iraq and Afghanistan. Hoge’s research sounded the alarm for the military and the public alike.