Those four letters, shorthand for post-traumatic stress disorder, stand for all that can go wrong for a soldier when the enemy is no longer on the battlefield but is in the nightmares and memories that return with him to civilian life.
The Department of Veterans Affairs estimates that in the general population, about 7 percent of people suffer from PTSD at any given time, triggered by trauma or the death of a loved one. Among veterans who served in Iraq and Afghanistan, the number rises to between 11 percent and 20 percent. For Vietnam vets, it’s 30 percent.
Treating it is a priority, Congress insists.
Diagnosing it is crucial, doctors say.
Preventing it might be possible, according to two Binghamton alumni. Both are psychologists: Michael D. Matthews, PhD ’83, is at the United States Military Academy at West Point, and Albert “Skip” Rizzo, PhD ’91, is at the University of Southern California’s Institute for Creative Technologies.
Both are working at the intersection of psychology and neuroscience, where discoveries about genetic influences on personality and vulnerability to disease might someday be used to select soldiers for qualities such as leadership, fearlessness and even aggression. There’s another quality that Matthews and Rizzo believe is key to producing not just a better soldier, but a better civilian, too.
“The military does a good job of teaching its soldiers to kill. But it does not do a good job of teaching them to cope with it,” Matthews says.
Matthews has been an Air Force officer, a policeman and is now professor of engineering psychology at West Point.
Engineering psychology, he explains, is the study of human capabilities and limitations as they relate to the design and function of complex systems or environments. His research focuses on soldier performance and decision making in high-stress situations.
This year, he published a book titled Head Strong: How Psychology is Revolutionizing War (Oxford Press, 2014), which follows the arc of psychology in the military from the first intelligence tests, used in World War I (to determine who could be trained to fly planes and drive tanks, both new technologies), to tests that might be used later this century to handpick soldiers to fight a war we have not yet imagined.
“To be a soldier now, you must pass an aptitude test, be somewhat physically fit and not have a criminal history,” Matthews says. That’s not much different from the requirements in 1917.
“The ideal soldier,” he says, “is intelligent, can adapt quickly from one situation to another, possesses strong leadership skills, is culturally savvy, and is physically, mentally and emotionally fit. This is a lot to ask of anyone.”
Instead of asking, what if the soldier were just tested?
In the future, neuroscience and epigenetics (the study of how the environment affects the expression of genes) could yield simple genetic and endocrine tests that would reveal who will be resilient in combat and who will be most vulnerable to PTSD.
“These biobehavioral tests will allow military testing centers to screen applicants on the basis of their genetic and constitutional proclivities for adjusting to military life,” Matthews writes. “Those who are vulnerable to the psychological impact of war may be assigned to noncombat jobs or referred to jobs outside the military. Those with exceptional resilience potential may be steered toward Special Forces and other military occupations that require the most from their members.”
Rizzo says we needn’t rely just on our DNA for resilience; he believes it can be taught.
Rizzo is a pioneer in the use of virtual reality to treat psychological issues ranging from autism to PTSD. Virtual Iraq/Afghanistan — first released in 2006 as Virtual Iraq — relies on exposure therapy to help service members with PTSD confront and process trauma-relevant emotional memories within a virtual reality simulation.
Here’s how it works: The soldier is immersed in a simulation of environments that trigger anxiety, letting him or her confront past traumas in a controlled manner. The soldier sees, hears, feels and even smells what’s going on in the place he’s in, while the clinician controls the intensity of the action — the fighting, the explosions, the tension. The goal is to help the soldier confront and process emotions rather than avoid them. The method is considered to be effective; it received the American Psychological Association’s 2010 Award for Outstanding Contributions to the Treatment of Trauma.
Now Rizzo has turned the model around, with the idea that letting soldiers confront the fear, the uncertainty and the kill-or-be-killed decision making before they go into combat will help them be better adjusted both on the battlefield and when they return to civilian life.
The result is STRIVE, which stands for “stress resilience in virtual environments.” Funding comes from the Department of Defense.
STRIVE uses a 30-chapter virtual reality program that replicates actual situations described by veterans with PTSD. Each scenario — an explosion, an injured child, an ambiguous threat — is intended to provoke physical and emotional stress. When the confrontation is over, a virtual mentor steps in and explains to the soldier how the body reacts to stress and offers physical, social and cognitive exercises that will help him or her build the behavioral and emotional components of resilience.
STRIVE won’t be assessed just on perceptions of resilience, it also will provide neuroscientific data. Physical testing will be done on the user to document allostatic load, which measures the wear and tear on the body from repeated episodes of disturbing stress.
By themselves, these stressors may show no impact. But cumulatively they can cause physical deterioration.
The resilience trainers will be used this fall at West Point in two courses: Human Computer Interaction and Human Factors Engineering. Cadets will learn how virtual reality integrates the senses — sight, sound, touch and smell — to engender emotions without diminishing the immersive perception, says Col. James Ness, associate professor and director of the Engineering Psychology Program.
“Our research interest is in the development of high-fidelity interfaces, and our teaching interest is to inspire cadets to do the same,” says Ness, who has experienced the trainer firsthand.
“I have tried it, and it does smell like the areas I experienced in deployment. The sensory experiences were compelling,” he says, “but there were some issues of poor tactical posture on patrol. I remember getting frustrated.
“Our goal is to inform Skip’s design through usability studies. We will also stand on the shoulders of Skip’s brilliance to ask more-informed questions about this type of interface design and how we might improve the immersive experience,” Ness says.
Instead of teaching resilience, how about prescribing it?
In Head Strong, Matthews raises the possibility that advances in brain imaging and gene research could lead to the manipulation of genes that control behavior. For instance, a soldier could be given a drug that causes him to be more aggressive during combat missions.
Other interventions might be used to keep soldiers alert and effective during extended military operations. Research is now being done on the use of beta blockers as a means of blunting the emotional reaction to trauma.
Working with Ness in a research project, some cadets are examining the relationship between the p11 protein and emotional adjustment in a sample of their peers, controlling for light exposure, throughout the academic year. The p11 protein has been implicated in the regulation of mood.
The findings may help scientists better understand the role of proteins in depression — results that can have important implications outside the military, too.
“Physical tests may someday include brain scans, neuroendocrine functioning and genetic assays. This will allow the military to better match the soldier to the job,” Matthews writes. But, he says, there’s a fine balance in developing soldiers who can kill an enemy and then return to civilian society and resume a healthy, well-adjusted life.
“It would be unethical to all involved if we developed a pharmacological intervention that eliminated post-traumatic stress disorder at the expense of eliminating the repulsion of killing. I would not want such a person living next door to me, and you would not, either.
“As brain science advances, the need for careful oversight and ethical review becomes increasingly important,” Matthews says. “Psychologists need to help the military develop selection tests that tap into skills and aptitudes that the 21st century soldier must possess, such as high stress tolerance, emotional resilience and cultural understanding.”
His students, he says, are excited about the science and about what may become possible in the future.
“We have engaging discussions about how far science should go in altering human reaction to trauma and adversity. The cadets see value in developing psychological or neuroscience-based interventions to reduce the odds of a pathologic reaction to stress. But at the same time, they do not want soldiers to become heartless automatons.”
Disclaimer: The views expressed by Col. James Ness are his own and do not reflect the official policy or position of the U.S. Military Academy, Department of the Army, Department of Defense or the U.S. Government.
The Psychology of Fear is just one of several videos of talks Skip Rizzo has given about PTSD. Search for others on YouTube.