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Virtual Reality Applications for Stress Management Training in the Military

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DOI: 10.3367/AMHP.4596.2016

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AEROSPACE MEDICINE AND HUMAN PERFORMANCE Vol. 87, No. 12 December 2016 1

R E V I E W A R T I C L E

Military forces perform complex and stressful activities wherein several emotional and cognitive factors come into play. War is perhaps one of the most chal-

lenging situations that an individual can experience, and the challenges are exacerbated by the multifaceted, changeable, and ambiguous contemporary operating space. 59 , 73 Th e physi-cal, emotional, cognitive, and psychological demands of a combat environment place enormous stress on even the best-prepared military soldiers 15 , 37 , 79 , and aircrew profession-als, such as warfi ghters 19 , 55 , 58 and helicopter pilots. 28 Moreover, stress can reduce operational eff ectiveness, 37 , 50 , 53 fl ight per-formance, 28 , 81 and even lead to major psychological disorders, including posttraumatic stress disorder (PTSD), 1 , 30 , 60 anxiety, and depression. 8 , 33

In a military context, stressors can come in a variety of forms, including physical (e.g., extreme heat or lighting, lack of sleep, dehydration, and impaired nutritional status) and

psychological (e.g., fear, risk of injury or death, time pressure, heavy workload, uncertainty, and information overload) 14 , 50 , 72 ,

Interestingly, in recent years increased attention has been given to programs for enhancing psychological resilience — the process of coping with or overcoming exposure to adversity or stress 6 , 85 — and specifi c training programs have been developed to support military personnel, as soldiers 16 and warfi ghter. 41 , 80 Guidelines have been developed to deal with combat stress, 3 , 12 , 13

From the Centre for Studies in Communication Sciences CESCOM, Department of Human Sciences for Education “ Riccardo Massa ” , University of Milano-Bicocca, Milan, Italy, and the Leonardo-Finmeccanica Airborne & Space Division, Rome, Italy. Th is manuscript was received for review in February 2016 . It was accepted for publication in September 2016 . Address correspondence to: Federica Pallavicini, Department of Human Sciences for Education “ Riccardo Massa ” , University of Milano-Bicocca, Piazza Dell'Ateneo Nuovo 1, 20126 Milano. Italy; federica.pallavicini@gmail.com . Reprint & Copyright © by the Aerospace Medical Association, Alexandria, VA. DOI: 10.3357/AMHP.4596.2016

Virtual Reality Applications for Stress Management Training in the Military Federica Pallavicini ; Luca Argenton ; Nicola Toniazzi ; Luciana Aceti ; Fabrizia Mantovani

INTRODUCTION: Stress Management Training programs are increasingly being adopted in the military fi eld for resilience empowerment and primary stress prevention. In the last several years, advanced technologies (virtual reality in particular) have been integrated in order to develop more innovative and eff ective stress training programs for military personnel, including soldiers, pilots and other aircrew professionals. This systematic review describes experimental studies that have been conducted in recent years to test the eff ectiveness of virtual reality-based Stress Management Training programs developed for military personnel. This promising state-of-the-art technology has the potential to be a successful new approach in empowering soldiers and increasing their resilience to stress.

METHODS: To provide an overview from 2001 to 2016 of the application of virtual reality for Stress Management Training programs developed for the military, a computer-based search for relevant publications was performed in several databases. Databases used in the search were PsycINFO, Web of Science (Web of Knowledge), PubMed, and Medline. The search string was: ( “ Virtual Reality ” ) AND ( “ Military ” ) AND [ “ Stress Training ” OR ( “ Stress Management ” )].

RESULTS: There were 14 studies that met the inclusion criteria and were included in the review. DISCUSSION: The main observation to be drawn from this review is that virtual reality can provide interactive Stress Management

Training to decrease levels of perceived stress and negative aff ect in military personnel. This technology appears to be a promising tool for assessing individuals ’ resilience to stress and for identifying the impact that stress can have on physiological reactivity and performance.

KEYWORDS: stress management training , virtual reality , military .

Pallavicini F, Argenton L, Toniazzi N, Aceti L, Mantovani F. Virtual realtiy applications for stress management training in the military . Aerosp Med Hum Perform. 2016; 87(12): 1 – 10 .

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VR STRESS MANAGEMENT TRAINING — Pallavicini et al.

including coping strategies to implement before deployment to a combat zone, during deployment, and when returning home. 72

Although few, if any, individuals are likely to be completely immune to the eff ects of stress on performance, there are inter-vening variables known as “ moderators ” that can reduce the performance decrement caused by stress. 37 One of the most studied and most eff ective moderators is training. 27 Stress train-ing can help military personnel handle emotional and physio-logical responses to stressors in order to maintain optimum performance even in situations of high stress. 25 , 37 , 44

In psychiatric literature, the term “ Stress Management Training ” (SMT) is not a single and selective concept. Most approaches usually contain elements of both relaxation and cognitive coping skills for preventing and managing stress. 18 In general, SMT can be defi ned as the application of any set of techniques (e.g., relaxation, biofeedback, and cognitive behav-ioral therapy) with the intent to improve the way people cope with stress. 4 Most research on the eff ects of SMT programs focuses on two main types of training: Stress Inoculation Train-ing (SIT) and Resilience Training (RT). While SIT programs aim to build stress tolerance through exposure, RT programs teach stress management techniques.

SIT was born from clinical psychology as a cognitive-behavioral treatment 47 – 49 to help individuals cope with the consequences of being exposed to stressful events. In the mili-tary fi eld, the purpose of SMT programs is to repeatedly expose soldiers to specifi c stressors and ask them to perform a target task while under the stress. Hence, SIT can gradually lessen an individual ’ s physiological response to a stimulus by reducing its novelty. 27 Th rough training, individuals may also learn how to manage uncertainty 22 , 69 and maintain high levels of perfor-mance despite its presence. 19 , 33 , 60 Several military programs incorporate SIT techniques. Examples include: 1) Survival, Evasion, Resistance and Escape (SERE), 26 , 82 , 83 which provides U.S. military personnel, U.S. Department of Defense civilians, and private military contractors with training in survival skills, evading capture, and the military code of conduct; and 2) Men-tal Readiness Training (MRT), 84 which was developed for the Canadian Armed Forces.

Resilience training (RT), i.e., the instruction of stress coping mechanisms while in a nonstressful setting, has been shown to reduce subjective stress assessments and increase performance of individuals. 26 , 64 , 74 While the term “ resilience ” is conceptual-ized in a number of diff erent ways in the academic literature, the term broadly refers to an individual ’ s capacity to maintain a functional equilibrium or display positive adaptation following or in spite of risks to normal development or psychological health. 7 Some of the most important programs developed in this area are the Comprehensive Soldier & Family Fitness Pro-gram (CSF2, U.S. Army), 20 , 34 , 64 designed to build resilience and enhance the performance of soldiers, their families, and U.S. Army civilians, and the Army ’ s Resilience Training Program (Battlemind Training, U.S. Army) 2 , 17 built as an integration of resiliency training for support populations throughout existing soldier, leader, and unit strengths.

In recent years the use of virtual reality (VR) has been extended to diff erent traditional SMTs, including SIT and RT programs. 29 , 56 , 61 SIT programs have been recently implemented in cyber-interventions (cyber-SIT), which through advanced technologies recreate simulations to teach individuals how to eff ectively cope with psychological stress. 70 , 79 , 86 With respect to RT, VR can help stressed or anxious individuals acquire eff ec-tive coping skills, such as relaxation strategies 29 , 31 , 61 and bio-feedback training. 55 , 57 , 71

By defi nition, VR is an application that lets users navigate and interact with a three-dimensional computer-generated (and computer-maintained) environment in real-time. 62 Research studies have compared the effi cacy of VR in inducing an emo-tional response with that of other media and/or real-life reac-tions, reporting that exposure to virtual stimuli produces emotional and behavioral responses similar to those that occur in the real world. 32 , 45 In addition, VR has recently been proven able to elicit emotions related to complex real-life stressors. 56 , 57

In the military fi eld, the use of VR for SMT is increasingly common. 16 , 66 , 76 Until a few years ago this technology had been used in a military context almost exclusively for the treatment of disorders associated with exposure to stressful situations, especially PTSD. 23 , 24 and for fl ight simulation 3 , 5 , 46 .

VR has become a topic of increasing interest to the military because it simulates highly stressful and complex scenarios in a safe environment. In addition, this technology is customizable, dynamic, and less expensive than other methods. 42 , 66 , 67

In the current review we will describe experimental studies that have been conducted since 2001 to test the eff ectiveness of VR-based SMTs developed for military personnel in order to show how this emerging state-of-the-art approach can improve soldiers ’ resilience to stress.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. 51

To provide an overview of VR-based SMT programs devel-oped for military personnel, a computer-based search for rele-vant publications was performed in several databases. Databases used in the search were PsycINFO, Web of Science (Web of Knowledge), PubMed, and Scopus. Th e search string was: ( “ Virtual Reality ” ) AND ( “ Military ” ) AND [( “ StressTraining ” ) OR ( “ Stress Management ” )].

To avoid the risk of bias, PRISMA recommendations for systematic literature analysis have been strictly followed. Th ree authors independently selected paper abstracts and titles, analyzed the full papers that met the inclusion criteria, and resolved any disagreements through consensus. Th e articles were individually scanned to examine whether they fulfi lled the following inclusion criteria: 1) research article; 2) provide information about the used sample; and 3) provide informa-tion about measures.

In the current systematic review, we aim to analyze experi-mental studies (from 2001 to 2016) focused on the use of VR

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VR STRESS MANAGEMENT TRAINING — Pallavicini et al.

for SMT programs geared toward military personnel to provide crucial indications for future studies and interventions. To this end, several aspects of the selected studies will be fully reviewed and discussed: 1) participants; 2) experimental design; 3) type of task used; and 4) the main outcomes for each study.

RESULTS

Th e fl ow chart of the systematic review is shown in Fig. 1 . Our initial search in PsycINFO, Web of Science (Web of Knowl-edge), PubMed, and Scopus yielded 76 nonduplicate cita-tions. Aft er the application of the inclusion criteria, 20 articles remained. A deeper investigation of the full papers resulted in the exclusion of another 6 articles. In the end, only 14 studies met the full criteria and were included in this review.

Th e fi rst important application of VR-based SMT programs for the military is cyber-interventions (cyber-SIT) programs, developed to expose soldiers to high-stress situations in order to improve their responses and performance under stress ( Table I ).

In the fi rst study, Stetz et al. 77 tested 25 soldiers (fi rst respond-ers or “ medics ” ) with VR training that consisted of a virtual environment being shown while the soldiers performed tasks in a stressful combat casualty environment. Participants were divided into four groups: virtual scenarios only, relaxation tech-niques only, both, or neither. Participants received feedback on their psychological and physiological stress levels and practiced coping strategies (e.g., combat breathing). Results showed that

participants who learned coping techniques during the VR training generally enjoyed the environment and experienced little to no discomfort while navigating within the environ-ment. Comparative analyses indicated that the virtual environ-ment did increase levels of posttreatment anxiety and dysphoria.

In a second study, the same author 78 investigated the use-fulness of a cyber-SIT program to increase levels of stress in medical military personnel. Sixty-three volunteers who were attending a combat medical class (e.g., Flight Medic, Joint En-route Care Course, Ranger First Responder) were placed in groups to practice combat medical skills with virtual scenar-ios only, relaxation techniques only, both, or neither. Higher levels of hostility were observed in the VR group than in the rest. Also, participants practicing relaxation techniques while exposed to the virtual scenarios showed higher levels of sensation-seeking. Interestingly, further analyses showed higher levels of both anxiety and dysphoria in those previously deployed who participated either in the VR or the relaxation group. Results suggested that exposure to VR scenarios involv-ing medical skills could be a promising way to prepare soldiers for combat stress.

Some years later, Hourani et al. 35 conducted a controlled pilot study to compare the efficacy of a cyber-SIT program called PRESIT with Combat and Operational Stress Control (COSC), 18 , 68 the current best practice. Th e purpose of the study was to use a Multimedia Stressor Environment (MSE) to induce a psycho-physiological arousal response during a simulated training mission and to assess the ability of participants to respond quickly and accurately to visual stimuli presented

during the mission. The MSE (a moderate-sized Iraqi village developed as a virtual scenario) was presented to a viewing group of 20 participants. Results showed that participants with deploy-ment experience demonstrated improvement, which was mea-sured as greater relaxation dur-ing the MSE when it was shown again in a follow-up session. In addition, participants with more PTSD symptoms showed more capability for improvement, as was true for participants who were more anxious about their next deployment.

Four other papers have recently reported on experimental stud-ies conducted during a 5-yr partnership between the Depart-ment of Psychiatry and Combat Stress (DP&CS) at the Military Institute of Medicine in Warsaw with the Virtual Reality Medical Center (VRMC) of San Diego. Th e training program consisted

Fig. 1. The fl ow chart of the systematic review.

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VR STRESS MANAGEMENT TRAINING — Pallavicini et al.

of physiological control exposure to a virtual stressor while maintaining physiological control.

In the fi rst study, Zbyszewski et al. 88 conducted a study investigating the impact of personality, temperament, and stress coping factors in a cyber-SIT program in soldiers preparing for their fi rst deployment to Afghanistan (ISAF). Th ere were 120 soldiers that were split into two groups of 60 people each: the Experimental (EG) and the Control (CG) Group. Soldiers from the EG, split into 4 subgroups of 15 each, took part in 10 SIT sessions. Both main groups fi lled out self-report questionnaires assessing coping skills, personality, and anxiety level. Results showed that before the SIT program, in the EG there was a neg-ative correlation between values in anxiety and briskness, sensory threshold, and endurance; there was a positive correla-tion between anxiety levels and emotional reactivity. Aft er the SIT program, in the EG there was a correlation between trait

anxiety values and emotional reactivity. Th ese results can be taken into account when analyzing individual susceptibility to SIT programs.

In the second study, Maciolek et al. 43 evaluated the infl uence of this type of cyber-SIT on the anxiety levels of ISAF soldiers. Th ere were 118 soldiers who were selected randomly from the 1500-strong contingent that took part in the research. Th e sol-diers were split into two groups: the EG and the CG. Both groups listened to a lecture on the nature of stress, its symp-toms, and coping with stress. Soldiers from the EG were split into four subgroups, each taking part in ten SIT sessions over the next 5 d. At the same time, soldiers from the CG took part in the scheduled training in their military area. Results of self-report questionnaires showed that, aft er training, anxiety values in the EG were signifi cantly lower than in the CG. In addition, aft er deployment, both anxiety scores in the EG and the CG

Table I. Information About the Selected Studies on VR-Based Stress Inoculation Training Programs.

STUDY SAMPLE DESIGN CONDITION(S)VIRTUAL STRESS

INOCULATION TRAINING OUTCOMES Stetz et al. (2007) 77 25 soldiers Between subjects

designFour conditions Combat Medic Scenario;

Individual trainingParticipants who learned

coping techniques during the VR training enjoyed the environment, and experience minor to no discomfort while navigating within the environment

Stetz et al. (2008) 78 63 soldiers Between subjects design

Four conditions Combat Medic Scenario; Individual training

Exposure to VR scenarios where to practice medical skills could be a promising way to prepare warfi ghters for combat stress

Hourani et al. (2011) 35 77 marines Between subjects design

Two conditions: 1) VR-based training group (EG); 2) no training group (CG)

PRESIT;Multimedia Stressor

Environment (MSE) scenario

Participants with deployment experience and who were in the experimental group showed greater relaxation during the MSE scenario;

Zbyszewski et al. (2013) 88 120 soldiers Between subjects design

Two conditions: 1) VR-based training group (EG); 2) no training group (CG)

Physiological control exposure to virtual stressor;

Training was delivered in subgroups of 15 soldiers

After the training there was a correlation between anxiety trait values and emotional reactivity

Maciolek et al. (2013) 43 118 soldiers Between subjects design

Two conditions: 1) VR-based training group (EG); 2) no training group (CG)

See Above-Training was delivered in

subgroups of 15 soldiers

After training, anxiety values in EG group were signifi cantly lower than in the CG;

Kosinska et al. (2013) 39 4 soldiers Within subjects design

One condition: 10 SIT sessions

See Above-Training was delivered in

subgroups of 4 soldiers

Two participants achieved better results in relaxation during fi nal exposition, when compared to the initial session; ì

Ilnicki et al. (2012) 36 118 soldiers Between subjects design

Two conditions: 1) VR-based training group (EG); 2) no training group (CG)

See AboveTraining was delivered in

subgroups of 15 soldiers

Short-term eff ectiveness of the training as a method of tension reduction.

In the long-term results were ambiguous

Winslow et al. (2015) 87 40 novice participants

Between subjects design

Two conditions: 1) VR-based training group (EG); 2) no training group (CG)

Five military-relevant training tasks under stress within Virtual Battlespace 2 (VBS2)

Utility of adding stressors external to the virtual training environments

Bouchard et al. (2011) 11 1.319 soldiers Within subjects design

A review and analysis of the available literature and of data collected post-deployment from respondents, recruited within Canadian Forces

Three sources were included Identifi cation of several stressful situations that could be used in VEs

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VR STRESS MANAGEMENT TRAINING — Pallavicini et al.

were signifi cantly lower compared to values before training. Authors stated that, given the equivocal results of the experi-ment, further study and deeper analysis were necessary.

In the third study, Kosinska et al. 39 evaluated the eff ective-ness of the same cyber-SIT program on four ISAF soldiers and then assessed whether the soldiers ’ temperament structure was related to successful training. Soldiers took part in 10 SIT sessions over 5 d. Th e initial and fi nal arousal/relaxation in response to VR exposition was assessed using heart rate (HR) indexes, while the temperament traits and structure were assessed using a self-report questionnaire. Th e analysis of HR indexes showed that three soldiers succeeded in reducing their arousal during the fi nal session. Two of them achieved better results in relaxation during the fi nal exposition when compared to the initial session. Th ree of the soldiers could eff ectively reduce arousal aft er the exposition as an eff ect of the training. Regarding the temperament structure, greater harmony was found in soldiers who achieved weaker results in training.

Finally, Ilnicki et al. 36 investigated the eff ectiveness of a short collective cyber-SIT program conducted according to the same methodology developed by the VRMC. Th ere were 118 soldiers from the 1500-strong Polish military contingent in Afghanistan that were split into two groups: the EG and the CG. Results showed short-term eff ectiveness of the cyber-SIT program as a method of tension reduction. However, in the long term, results were ambiguous and authors suggested the need for further research.

In another recent study, Winslow et al. 87 investigated how stress induction through a virtual environment compares to and is infl uenced by the gold standard of socio-evaluative stress, the Trier Social Stress Test (TSST). 38 Th ere were 40 novice par-ticipants divided into Experimental (EG) and Control Groups (CG). Participants ’ physiological and psychological stress lev-els were assessed. Aft er the collection of baseline measure-ments, the EG was exposed to the TSST, while the CG was not. Th en, all the participants performed fi ve military-relevant training tasks under stress within Virtual Battlespace 2 (VBS2, Bohemia, Orlando, FL), a VE used for military training. Results showed that virtual stressors alone may not be suffi cient to induce a signifi cant stress response (i.e., cortisol levels did not increase signifi cantly aft er the exposure to stressful virtual sce-narios). Indeed, analysis indicates the utility of adding stressors external to virtual training environments. Interestingly, base-line stress measurements were predictive of individual resil-ience to stress, including the impact stress had on physiological reactivity and performance under stress.

Only one study focused on the procedures followed to identify several stressful situations that could be used in VEs designed to train military personnel in stress management techniques. 11 The aim was to list VEs that are significantly stressful and specifi c enough to allow a reduction in the likeli-hood of developing PTSD. A review and analysis of the avail-able literature and of data collected post-deployment from 1319 respondents (recruited by the Canadian Forces) about the frequency of stressors and their association with psycho-logical injuries were pulled together to propose potential virtual

stressors. Stressor selection was based on a few criteria, such as a frequency of occurrence of at least 50% among military per-sonnel who were involved in active combat and the feasibility of recreating the stressor in VR. Aft er submitting stressors to these criteria, eight stressful situations stood out (e.g., seeing dead bodies or uncovering human remains and knowing that some-one has been seriously injured or killed).

Another area of extreme interest to the military related to the fi eld of VR-based SMT programs is Resilience Training (RT), which aims to teach stress management techniques to sol-diers to increase their stress tolerance ( Table II ).

Th e fi rst study conducted in this fi eld was to test receptivity to stress management techniques taught through virtual scenar-ios by military service members. 75 Th ere were 60 soldiers were randomly assigned and equally distributed to either an Experi-mental Group (EG) or a Control Group (CG). For three con-secutive days, the EG looked at a video of a virtual island zone that contained an embedded script explaining how to practice relaxation techniques (e.g., progressive muscle relaxation). Anal-yses of surveys and a focus group suggested that EG partici-pants not only liked practicing relaxation techniques, but would also continue practicing these aft er the completion of the study.

In a second study, Bosse et al. 10 investigated the impact of virtual training on the subjects ’ experienced stress responses. Driven by the goal to develop a virtual environment capable of training for mental readiness, the main research question was whether it is possible at all for such an environment to obtain a learned eff ect of successfully lowering subjects ’ stress responses in future situations. Th ere were 10 healthy adults who partici-pated in the experiment and were randomly assigned to either the EG or the CG. Th e CG participated in two rounds separated by a 6-h break. In these rounds participants were shown 150 images from the IAPS picture set. 40 Aft er each image, partici-pants were asked to rate the emotional intensity of the picture. Th e EG also participated in these rounds. However, in between these two rounds, the EG participated in a virtual training ses-sion. Th e virtual training used the same pictures as the other rounds. But instead of rating them with a grade, the partici-pants were asked to view the pictures while actively reducing their emotional response until they felt comfortable looking at the picture. Th e training resulted in signifi cantly lower ratings of the images in the second test. In particular, the overall drop in emotional ratings of the training group was signifi cant, while the change in emotional ratings for the control group was not signifi cant.

Th e same authors replicated this study on a diff erent sample in a second experiment 11 to investigate what type of VR-based RT could be the most appropriate in order to obtain a successful decrease of emotional responses toward negative stimuli. Th ere were 15 healthy adults who participated in the experiment and were randomly assigned to 1 of 3 groups: a fi rst group perform-ing a session of virtual training in between these time points (EG 1), a second group performing virtual training thereby applying reappraisal strategies (EG 2), and a group without any training session (CG). In these rounds, 150 images from the IAPS picture set 36 were shown to the participants following the

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same procedure of the previous study. 9 Both EGs also partici-pated in these rounds, just like the CG. However, in between these two rounds, the EGs performed a virtual training session. In addition to the above, the participants in all three groups participated in a second part of the experiment that aft ernoon and then 6 mo aft er the fi rst part. Results showed that the EG 1 resulted in a signifi cant increase of emotional ratings for nega-tive images, while EG 2 signifi cantly decreased emotional rat-ings for those images.

Morie et al. 52 conducted a preliminary study that measured mood and arousal eff ects produced by engaging in a biofeed-back (virtual jogging) scenario where control of the avatar is achieved via steady, rhythmic breathing. Th ere were 27 partici-pants, not specifi cally selected from the veteran population, who used a male avatar wearing Army fatigues and were tested at the same virtual location within Second Life. Results on self-report questionnaires showed that participants ’ experiences using the jogging path had eff ects on these measures, resulting in a signifi cant decline in mean scores for all three scales. Over-all, results indicate that the virtual jogging activity, in its totality, tended to help participants feel more relaxed and calm.

Stetz et al. 76 conducted another study with the aim to test the eff ectiveness of a VR-based RT based on progressive muscle relaxation (PMR) and controlled breathing (CB) techniques. Th ere were 60 military medical warriors who participated in the study and were divided in 2 groups: the EG and the CG. For three consecutive mornings, participants in the EG were presented with virtual calming and relaxing environments while prac-ticing PMR and CB techniques. Th e participants also engaged in two stressful hands-on tasks (simulations of surgery). Results on self-report questionnaires showed that participants in the EG were less anxious post-immersive relaxation training as com-pared to the CG. In addition, even if the VR-assisted relaxation techniques were unable to be evaluated during stressful situa-tions (i.e., the stressful tasks failed to increase participants ’ anxi-ety levels), they were successful in reducing overall anxiety scores.

DISCUSSION

SMT programs are increasingly being adopted in the mili-tary field for soldiers ’ and aircrew professionals ’ resilience

Table II. Information About the Selected Studies on VR-Based Resilience Training Programs.

STUDY SAMPLE DESIGN CONDITION(S)VIRTUAL RESILIENCE

TRAINING OUTCOMES Stetz et al. (2009) 75 60 soldiers Between subjects

designTwo conditions: 1) VR-based training group (EG); 2) no training group (CG)

“ Dream Island ” , a virtual environment that embedded script explaining how to practice Progressive Muscle Relaxation and Controlled Breathing

- Participants not only liked practicing relaxation techniques through VR scenarios but would also continue practicing these after completion of the study

Bosse et al. (2012) 10 10 healthy adults

Between subjects design

Two conditions: 1) VR-based training group (EG); 2) no training group (CG)

Emotional pictures were shown while participants were asked to actively reducing the emotional response until they felt comfortable looking at the picture

- The VR-based training resulted in signifi cantly lower ratings of the images supporting the hypothesis that reappraisal-based virtual training can be used to reduce subjects ’ emotional responses to negative stimuli at later times

Bosse et al. (2013) 9 15 healthy adults

Between subjects design

Three conditions: 1) VR-based training group 1 (EG1); 2) VR-based training group 2 (EG2); 3) no training group (CG)

Emotional pictures were shown while participants were asked to actively reducing the emotional response until they felt comfortable looking at the picture or to apply reappraisal strategies

- The VR-based training applying reappraisal strategies could be the most appropriate in order to obtain a successful decrease of emotional responses toward negative stimuli with a long-term eff ects of training

Morie et al. (2011) 52 27 healthy adults

Within subjects design

One condition: Virtual Biofeedback

A virtual jogging path, developed within Second Life ™ , where control of the avatar is done via rhythmic breathing

- The virtual jogging activity tends to help participants feel more relaxed and calm. While there was a decline in some positive emotions such as inspired and enthusiastic, there was a signifi cant decline in the negative emotions as well

Stetz et al. (2011) 76 60 military medical warriors

Between subjects design

Two conditions: 1) VR-based training group (EG); 2) no training group (CG)

For three consecutive mornings a virtual calming environments was presented while practicing relaxation techniques

- The VR-based relaxation techniques were successful in reducing overall anxiety levels

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empowerment and primary stress prevention. 16 , 74 Stress can worsen the performance, aff ecting individuals ’ cognitive and emotional processes. Th us, knowing how to manage stress is a fundamental skill for military personnel that can have an impact on job performance, as well as on emotional and physi-cal health. 12 , 37 , 54 In recent years, advanced technologies includ-ing virtual reality have been included in SMT in order to develop more innovative and eff ective training. 29 , 65 Here, we focused specifi cally on SMT programs for military personnel that integrated virtual reality in order to describe this emerging and promising approach to improving resilience to stress.

Th e main observation to be drawn from this review is that VR-based SMT programs (both developed on SIT and RT pro-grams) can reduce subjects ’ emotional responses to negative stimuli, 35 , 39 even at later times. 9 , 10 Th is type of training, there-fore, can help military personnel handle emotional and physi-ological responses to stressors in order to maintain performance even in situations of high stress.

Interestingly, VR also appears to be a promising tool to assess individuals ’ resilience to stress and to identify the impact that stress can have on physiological reactivity and perfor-mance. 87 Virtual stressful scenarios can be used to assess the physiological response to stressors and correlate that response to task performance, making it possible to train practitioners to identify resilient individuals or those at risk for stress-related performance issues.

Th e third important observation that emerges from this review is that VR can also be used to provide interactive SMT programs useful for decreasing levels of perceived stress and negative aff ect in military personnel. 9 , 52 , 76 In particular, the review showed that virtual environments combined with arousal reduction strategies (e.g., systematic desensitization through exposure to stressful scenarios, traditional relaxation and biofeedback techniques) eff ectively increase military resil-ience to stress.

According to the results of this systematic review, SMT programs based on VR applications appear to be a promising approach; there are even studies that have eff ectively combined traditional SMT protocol with VR technology. However, there are some methodological challenges.

Th e fi rst challenge is the number of studies carried out in this research fi eld. Because it is an emerging fi eld of research, there are still relatively few studies in the literature that meet the requirement of using VR in SMT programs. Most of the studies, in fact, have VR-based SMT programs only in theory, without providing data about trials conducted to test the eff ectiveness of the proposed approaches. In particular, we could not include in the review important programs developed in recent years for SMT that integrate VR as a “ virtual reality adaptive stimulation ” (VRAS) or “ Stress Resilience in Virtual Environments ” (STRIVE). VRAS is a predeployment mental stress resistance training, based on the use of virtual reality that was developed for the assessment of emotional and behavioral control of Interna-tional Security Assistance Force (ISAF) soldiers, whose mental health is an important indicator of NATO ’ s readiness. 20 , 21 , 68 Th e STRIVE project builds on the Virtual Iraq/Afghanistan

simulations developed for VRET 63 , 68 to create a series of immer-sive virtual interactive narrative episodes that present examples of the types of emotional challenges soldiers may face during deployment. It has developed and disseminated training that aims to improve the emotional coping skills and resilience of soldiers. 67 Although VRAS and STRIVE are both complex and innovative programs that may provide important new ele-ments to SMT programs for military personnel, the lack of experimental studies signifi cantly limits their impact. As VR and, more generally, the adoption of advanced technologies (e.g., augmented reality, serious games) play a greater role in the future SMT military field, 58 it will become crucial that future studies be methodologically and numerically stronger to enhance the adoption of these technologies.

Th e second challenge, closely related to the fi rst, is that the experimental studies conducted to date have used few and heterogeneous measures to assess the eff ectiveness of the VR-based SMT programs that have been developed. Several studies included in this systematic review (e.g., Bosse et al. 9 , 10 ) do not include specifi c measures of individuals ’ stress levels before and aft er the VR-based training, making it very diffi cult to understand diff erences before and aft er SMT. In the future it will be important to defi ne a set of standard measures for the evaluation of the training. These measures should include: 1) individuals ’ subjective stress levels (e.g., self-report ques-tionnaires); 2) individuals ’ objective stress indexes (e.g., cortisol and HRV data); and 3) individuals ’ experience of the VR sys-tem (e.g., self-report, interviews, and observational data).

Th e third main challenge is that studies conducted to date have included only very small numbers of subjects, in some cases even recruited among military personnel. 52

A fourth and fi nal fundamental challenge is the lack of stan-dardized procedures used in the defi nition of SMT protocols based on the use of VR. Th is challenge regards all the ideation and development phases of this type of training. Th e following should be included: 1) the defi nition of the specifi c objectives of the training on the basis of the sample concerned; 2) defi nition of VR scenarios both for the gradual exposure to stressors and for the training of coping skills and resilience; and 3) the test of the eff ectiveness of the VR-based SMT program through the execution of clinical trials. To defi ne a series of “ best practices ” to be used in the development process of VR-based SMT could increase the ultimate eff ectiveness of any program developed.

ACKNOWLEDGMENTS

Authors and affi liations: Federica Pallavicini, Ph.D., M.D., Luca Argenton, Ph.D., M.D., and Fabrizia Mantovani, Ph.D., M.D., Department of Human Sci-ences for Education “ Riccardo Massa ” , Centre for Studies in Communication Sciences CESCOM, University of Milano-Bicocca, Milan, Italy; and Nicola Toni-azzi, M.D., Leonardo-Finmeccanica Airborne & Space Division, Rome, Italy.

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