Cognitive-Behavioral Treatment of PTSD Symptoms in Cyberspace

Alecsey Boldeskul

May, 2000



A growing body of evidence suggests that almost everyone has a high risk of psychological syndromes developing in response to exposure to stressors. The severity of these syndromes directly correlates with the intensity of the stressor and indirectly correlates with the level of the individual’s psychological tolerance. In the worst case, when tolerance is relatively low and the stressor is extreme, an individual may develop a syndrome known as posttraumatic stress disorder (PTSD), a very serious condition that requires medical intervention. PTSD, which is sometimes called posttraumatic illness, has a rather high prevalence rate, because many Americans are exposed to stressors on a daily basis while they are short of stress management skills (O’Brien 2). War, car and train accidents, plane crashes, physical and sexual assaults, deaths of relatives or friends, lethal diagnosis, exposure to natural disasters, and similar events have the potential to overcome an individual’s psychological tolerance and evoke PTSD. Specifics of some professions, such as police officers, firefighters, paramedics, rescue workers, and military personnel, can also involve frequent exposure to extreme stressors (Clohessy 256; Lipton 100). Furthermore, some work-place stressors classified as non-extreme are shown to be PTDS inducing. Finally, increasing violence in American schools deserves serious attention, because witnessing traumatic events is also considered an extreme stressor, which puts exposed students under a high risk of developing PTSD.

Because an extreme stress can create serious effects on an individual’s mental health, people diagnosed with PTSD are often required to enter treatment. However, based on consideration of the availability and affordability of professional help, as well as on the individual’s personal attitudes, some PTSD sufferers may decide not to do so (Rosenheck). There is also a category of people who may be unaware of their psychological syndrome. According to epidemiological studies on PTSD by the National Center for PTSD and the National Institute of Mental Health, approximately 3.6-4% (approx. 5 million people) of adults in the United States had PTSD during 1998, which accounts for 7.8% of life time prevalence of this syndrome. And despite high prevalence rates, PTSD therapy remains one of the nation’s most expensive health services compared to treatments of other psychological disorders. To reduce the cost of treatment, however, various non-traditional tools can be applied. For example, computer virtual reality (VR), when available, can replace ‘staged’ flooding therapy that requires assistance of other people or even actors to recreate a traumatic event (Johnson).

Virtual reality is the relatively new technology, researches and clinicians do not have enough knowledge on the possible impact that VRs would have on patients in the long run, in terms of recurring symptoms. However, the fact that VRs are shown to decrease PTSD symptoms within only few sessions points out its high potential. One day, when broadband Internet connections and VR helmets become the commodities, VRs will be widely deployed for medical and other purposes, but for now they are still very expensive, which would increase the cost of treatment. In the quest for less expensive PTDS treatment, this paper recommends using Internet-based multi-user dungeons (MUD) as a more cost-effective substitute for such expensive tools as a VR simulator. Although MUDs are relatively primitive text-based VRs, they could be beneficially used by both medical institutions and the individuals seeking self-help, to aid the cognitive-behavioral techniques in treatment of certain PTSD symptoms.

PTSD in Brief

Aetiology of posttraumatic illness involves two phases. The first phase, which is called acute stress syndrome, appears either during the traumatic event, or shortly after. The second phase, PTSD, seems to be a fixation of acute stress and usually comes in long-lasting chronic form. A common belief in the past that extreme stressors, relatively short in nature, should not be expected to evoke chronic stress syndromes led clinicians to fail to recognize PTSD as such. The Vietnam War ended a long ‘unofficial’ history of PTSD. After the Vietnam War, many veterans were reported to have lasting social and interpersonal problems, criminal behavior, substance abuse, and poor mental health (O’Brien 12). To classify veterans’ problems, the concept of PTSD was developed and was consequently applied to other groups of people traumatized by extremely stressful experiences. At last, posttraumatic stress disorder was officially acknowledged in 1980 when its symptoms and diagnostic criteria were included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (APA).

The latest updates on PTSD classify this syndrome as an anxiety disorder that develops after exposure to an event that lies "outside the range of usual human experience" (APA). A PTSD stressor (traumatic event) should involve either an actual or threatened death or injury, a threat to the victim’s physical integrity, destruction of the victim’s home or community, seeing another person who has recently been, or is being, seriously injured or killed, etc. According to the definition, a victim should be diagnosed with PTSD if he or she displays a triad of distinctive symptoms. (a) A victim is repeatedly re-experiencing traumatic events through recurrent images, intrusive recollections, thoughts, dreams, illusions, and flashbacks. (b) A victim is coping with re-experiencing by employing avoidance behavior, which includes avoiding thoughts, feelings, conversations, activities, places, or people that may trigger recollections of the trauma. Some victims may also develop psychogenic amnesia for important details of the traumatic event. (c) A PTSD sufferer should display increased arousal, which is expressed in nightmares followed by changes in sleeping pattern. Finally a number of other symptoms, such as irritability, aggressiveness, poor concentration, hypervigilance (increased alertness), and emotional anesthesia should be present.

A number of approaches, generally grouped into the three categories, have been employed in the treatment of PTSD (Ochberg; Hendin; Friedman; Bisson; Parson 239). And even though all three categories, psychotherapy, pharmacotherapy, and cognitive-behavioral therapy (CBT), were shown to have similar effectiveness, some empirical data suggest that CBT works slightly better than other treatments (Tarrier 192; Foa). CBT is also distinguished by its capacity to incorporate innovative therapeutic tools. Similarly, computer-assisted virtual reality exposure (VRE) was applied specifically to CBT. VRE was reported to be very effective in the treatment of flying anxiety (Baker). Using a VR helmet, a therapist exposed PTSD sufferers to a virtually reconstructed traumatic event. For example, patients who had a fear of flying were exposed to aspects of flight that frightened them the most. At first, patients showed increasing symptoms of anxiety and fear, but subsequently they were able to learn how to manage symptoms. Based on successful treatment of flight fears, VRE was later used in CBT of war veterans and victims of violence with PTSD. Now VRE is applied to a treatment of a wide range of symptoms, including fear of public speaking, fear of driving, and PTSD followed exposure to natural disasters. As with any other exposure techniques, VRE can cause recurrence and increasing intensity of PTSD symptoms, which usually leads to worsening of the PTSD condition. This is a normal reaction to reliving traumatic events, and most PTSD sufferers enrolled in exposure treatments inevitably have their PTSD symptoms intensified (O’Brien 228). If not interrupted at this stage, exposure treatments usually force PTSD symptoms to fade away. Because of the risk of intensification of PTSD symptoms, a patient should be told beforehand of all possible negative side effects of the treatment. When possible, a patient should undergo treatment under the careful control of a therapist. And if a serious problem occurs, exposure treatment should be interrupted.

MUD as the Model Environment

The acronym MUD stands for object-oriented interactive multi-user domain. It describes on line environments where multiple participants can be logged on to socialize, build their characters and virtual worlds, and role-play. There is a wide variety of MUDs ranging from friendly meet spaces that resemble on line chat rooms, to extreme role-play cyber-punk games (Reid). While such social domains as TinyMUDs or MUSHes serve recreational purposes, cyber-punk MUDs are regarded as cruel and violent virtual worlds where character killing, rape, and theft are common elements of role-playing.

Everything in the MUD, places, characters, and actions, are represented in textual mode, which seems to be a disadvantage compared to realistic 3D projections of VR. However, this disadvantage is balanced by the interactivity of the MUD, and by the fact that VR is not generally available to the public. Additionally being exposed to the textual cues as opposed to graphical cues may be more beneficial in treating certain PTSD symptoms. While, in many cases, VR is a two-component system consisting of a single user and computer, MUD can be viewed as a multidimensional system where numerous users are interacting through the computer networks. Here, interactivity means that MUD users are "able to do things to one another" (Bartle), which should broaden practical implications of MUDs. This MUD interactivity opens up a debate on the issue of role-play violence and its possible effects on emotional and psychological health on individuals behind their characters. In the case of social MUD, violence is simple and largely limited to verbal abuse, but when it comes to role-play in highly hostile cyber-punk environments, the concept of on line violence becomes much more complicated. Early computer-mediated communications (CMC) researchers claimed that role-play violence caused no harm because there was no physical connection between the character and the body. However, later investigations gave the argument that some MUD users have strong cognitive connections with their characters, and in the case of cyber assault it is the user’s consciousness, not the character, who becomes the primary victim (Turkle 12; MacKinnon 6; Stone 111; Novak 226; Morningstar 291). Still, there is no strong evidence supporting either side, and the question of whether or not MUD violence is traumatizing is still to be answered.

For the purpose of this paper, the question of the traumatizing power of MUD violence perhaps should be neglected. In either case, MUD causes traumatization or multi-user dungeon simulates violence without traumatizing role-players, the system should be able to trigger reliving of the traumatic memories by a PTSD sufferer otherwise the therapy will not work. Given psychological variety of different levels of stress tolerance among role-players, MUD should pose both traumatizing and non-traumatizing effects. In a test of this hypothesis, I interviewed fifty-seven randomly selected current and former MUD role-players, and the results generally supported the hypothesis. 66.7% of the sample (38 role-players) reported negative reactions ranging from sadness of being defeated to acute trauma and temporary abstention from role-playing, in response to their characters’ deaths for the first time. All thirty-eight players also reported some history of character deaths, but the rate of emotional reactions among them declined. 31.6% reported annoyance and frustration, and at least half of them completely abandoned MUD RPG environment. The other 68.4% of those thirty-eight role-players quickly changed their strategy and tactics generally aimed to avoid their character dying in the future.

This study, which at no event should be considered comprehensive and quantitatively reliable, nevertheless, points out a possibility that MUD RPG can be quite effective in evoking emotional reactions especially among newcomers. It is not clear, however, what causes these reactions, real traumatization or perceived feeling of being traumatized. But this is what is required of MUD role-playing for successful intervention of posttraumatic stress symptoms.

A Cyberclimate for PTSD Treatment

The idea of using computer-mediated communications (CMC), such as chat room, MUD, or e-mail, to help people with psychological problems is not unknown to the world. There were several reports in the past on the successful application of CMC cognitive-behavioral therapy in the treatment of depression (Turkle 114), as well as several therapeutic software programs that have been developed. Suler calls psychotherapy delivered to a patient by means of CMC, ‘cybertherapy,’ which denotes a new loop of the evolution of mental health services. Is seems that ‘cybertherapy’ does not get the popularity it probably deserves, and only a small number of cyberspace oriented researchers and practitioners remain devoted (Barak; Powell; Sommers).

In the context of ‘cyberthearpy,’ MUD is usually mentioned within the pool of other CMCs. However, this medium is distinguished by several important characteristics that make MUD especially suitable for therapeutic purposes. MUD is the synchronous (real-time) environment where everyone can be the actor playing scenarios or owning fantasies (Quittner 95). Even though it is often thought of as the game, MUD should only formally be perceived as such. Microsoft Bookshelf defines a game as a "competitive activity or sport in which players contend with each other according to a set of rules." Apparently, MUD is not set for the competition. There is no score, winning, losing, or goals to achieve other than to participate. The lack of competition propels another important feature of the MUD that is it in general is a friendly environment.

MUDs are flourishing environments for such deviant behavior as character killing, harassing, and vandalizing, but in most cases these deviations occur in role-playing and may not be consistent with true intentions of a person behind the character (Bruckman). True, the demarcation line between in-character (IC) behavior, or role-playing, and out-of-character (OOC) behavior is often vague and formal. However, most of the users cannot repeatedly pose hostile IC behavior on other players because of the risk to annoy and repulse them, especially that most of the MUDders are addicted, or better to say devoted to their delusional worlds. Thus, it is not an unusual picture in the MUD when two characters are discussing various issues few minutes later after they were involved in a severe combat. A phenomenon of friendliness seems to be a balancing act between the delusional ‘naturalness’ of the MUD and its realization as the game. Multi-user, real-time nature of the MUD allows it to be highly realistic while remaining collaborative recreational activity.

In this perspective, friendliness should occupy more important place in the mind of player as opposed to the violent role-playing, which, while remaining extremely an important part of the MUD, can evoke only short lasting negative reactions. Certainly, there are some exceptions from this general rule. First of all, there is a special kind of role-player called "player killer" (PK), who devotes his or her time to repeatedly kill other characters. PKers is the special issue in the MUD because they usually introduce much of unexpected destruction into the gaming environmenti. PKers are hard to catch and they are usually quite powerful for an average player to battle with, which creates a tendency that many people actually turn away from some player kill intensive MUDs. This discussion is based on the interviews with 57 randomly selected MUD role-players.

Secondly, some users often become victims of extreme violence while on line; thus, they become disappointed with the idea of friendliness of the Mud environment. Cyber or virtual rape, for example, is one of the most common forms of extreme violence in the MUD, and not surprisingly, women become the primary victims. However, the later notion should be considered with care because of the high rates of cross-dressing in CMC environments (Danet 142). Perhaps, the most astonishing case of cyber rape, known as Mr. Bungle affair, happened in Lambda MOO in the early 1990s when a character, Mr. Bungle, forced several other characters to participate in his ‘sadistic fantasies’ (Dibbell). Dibbell’s account had a particular importance because it showed the world that traumatic events that happened in the MUD seriously influenced an individual behind the character. Secondly, Dibbell’s article triggered a discussion in which the whole concepts of rape, in cyberspace and in real world, were deconstructed and reconstructed to explain Mr. Bungle affair (MacKinnon).

While friendliness is the social attribute of the MUD, another important attribute that belongs to the technical part of the game needs to be considered. Characters, as well as anything else in the MUD are treated as the objects, which significantly enhances the player’s imaginal experience. If deprived of this feature, MUD would still have been a powerful medium, because it usually brings together more than one user at a time (Joyce). But using objects allows role-playing to become much more complicated. MOO (multi-user domain object-oriented) is a special breed of MUD, which allows users to describe places, things, and characters as objects. MOO is ‘filled’ with the objects that can be looked at, used, or destroyed. MOO players usually pay close attention to the objects, because they have graphical descriptions with embedded functionality clues. Here is how one of the rooms in Lambda MOO, one of the most populated dungeons, is described:

Rock Pool: The fissure opens out here into a small but obviously enlarged cavern. A placid

rock pool, almost too small to fit down but seemingly immensely deep, lies at the bottom of

a deep funnel in the northwest corner of the room. Leaning against the eastern wall is a stone

statue of an old and smiling man. You see ribcage breastplate, thighbone club, and scimitar, here.

Source:; port 8888

A player (character) is seeing several objects lying on the ground upon entering the rock pool. There is also a statue of an old man in this place. The statue is the key to solving one of the role-play puzzles, and, perhaps, it should be looked at more carefully. Typing a command ‘look statue’ (object) brings the following description:

A statue of an old man, sitting cross-legged and dressed in heavy robes, with a small deer

curled next to him. The statue's base has been removed, and the figure rests on the floor.

The finely carved rock has been hacked and marred by barbarous creatures, but the smile

on the old man's face remains. The statue has one eye made from a white crystal; the other

is missing, perhaps stolen for its mundane value.

Further examination of the statue will reveal that even its eye made from a white crystal is treated as the object and can be removed or stolen.

Given these examples, it is necessary to understand whether or not MOO objects (places, things) are treated by participants as visual elements as opposed to being mere text. Originally, MUDs were non object-oriented text-only environments, which placed significant limitations upon interactivity of the game. But it was the communicational (or cognitive) needs of participants that led to the development of object-oriented feature (Kolko 179). Text arranged in packets (objects), except for conversations and actions should be perceived as the transition between a linguistic form of what is read and cognitive pictures created by imagination. These imaginary pictures are the keys to understanding why MUDs are quite delusional. Certainly, not all of the participants are able to establish the textual-imaginary link between the MUD and the mind, but the solution is to either methodically practice conversion of text into mental pictures i.e. training imaginal skills, or by participating in already existing graphic-based MUDs. Another consideration worth mentioning here it that people who suffer from PTSD and other anxiety disorders tend to selectively deploy their attention towards threat words if exposed to the textual representations, which is particularly relevant to the case or text-based VRs (Clark S5).

Behavior modification is another important characteristic of MUD environment. Cyberspace itself seems to influence role-players by making them less inhibited while on line (Sempsey). In the context of MUD violence, disinhibition becomes a dilemma, it whether should be perceived as the positive or negative attribute of role-playing. For example, killing or raping another character is perceived as negative manifestations of disinhibition. Lack of empirical data doesn’t allow researchers to fully understand the mechanism of disinhibition in cyberspace. Some reasonable hypotheses propose that disinhibition occurs because of an anonymity and perceived immunity from physical retaliation (Sempsey). However, new studies showed that introduction of video/audio interface, which should have flawed anonymity, did not reduce disinhibitation (Marshall). Evidently, disinhibitation should contribute to successful treatment of posttraumatic stress disorder.

Finally, it is a widely accepted concept that many people prefer to ‘live’ on line, rather than in real world. People seem to display their devotion to this medium by spending long hours there. Zenhausen suggests that the rate of cyber addiction is high enough to attract the attention of psychologists. In fact, a preliminary draft of the DSM-V includes a section titled "cyber disorders," which is devoted to this subject. In contrast, a person dealing with PTSD, should perhaps have different approaches to this problem. Among other symptoms, some PTSD sufferers show ‘emotional anesthesia’ that reduces their interest and desire to participate in social activities. Such individuals should have motivational difficulties when entering treatment, and will need to undergo psychotherapeutic counseling to raise their interest in outcomes of treatment. But MUD, being highly addictive, should compensate sufferers’ emotional numbing and maintain level interest high enough to have them returning to the MUD for healing sessions.

Of course, this two-component therapeutic system, victim-MUD, should have certain prerequisites. A victim should spend certain amount hours in the MUD becoming familiar with scenario and basic functionality, i.e. movement, communication, and manipulation. The victim should set up a character on his own because, only through creative process and spending of mental energy and passion would attachment to the character and MUD environment be achieved. In general, the more attached PTSD sufferer becomes to his or her character, the more extensive his or her reaction will be on any unsuspected outcomes of role-playing. And actual treatment should be started as soon as an individual shows strong emotional reaction when the character dies.

Limitations of the MUD Environment

Not everyone can succeed in the MUD environment, which creates a necessity to discuss the profile of an average MUD user. Perhaps the simplest example would suggest that individuals who do not type or do not know how to use computer are not qualified. Individuals who cannot make a sense out of MUD and role-playing will not succeed either. Existing demographic data shows that the highest rates of MUD usage occur among 18 to 24 years old, which poses certain problems of compatibility with the other age groups (Reid). Stage theories of human development generally suggest that the cognitive set significantly varies as an individual moves along the life span, and the certain communicative obstacles may occur among people of different ages (Baron 347). It does not mean that MUD should be seen as the most appropriate tool for helping young adults only. Reid’s six years old study most likely represents MUD demographics incorrectly. Computers and the Internet are more accessible now than these were six years ago, and the age gap among MUD users should be somehow wider.

Another factor that may affect the social dynamics of MUD is its growing diversity. Multi-user dungeons can run on the weakest and cheapest computers with the only requirements to have the Internet connection with the ability to communicate basic ideas in English. And despite of lack of the both in many countries, the Internet becomes international and diverse. Certainly, lingual diversity isn’t the problem for MUD users from English-speaking countries, but it most likely to be the problem for non-English speakers.

Finally, MUD addiction can cause a patient spending more and more time role-playing or socializing in the MUD while real life problems remain unresolved. As the opposite effect, a patient may not be able to reach a level of integration with the environment; thus the MUD events will not have any influence on an individual. MUD role-playing provides an opportunity to create very sophisticated characters. And most of the participants, after many days of hard role-playing, and spending an enormous amount of creative energy, are able to bring their characters to the very high level of sophistication. Eventually, the character becomes of a great value to its owner strengthening his or her emotional response to the character’s success or failure. MUD as the tool of treating psychological disorders will most likely fail at the therapeutic facility, where people usually have limited amount of time to receive treatment, e.g. patients do not have enough time to establish strong bond with their characters and MUD environment. But if the individuals are determined to use MUD as the part of self-help system to treat PTSD symptoms, this problem does not seem to exist. There may be a problem of getting PTSD sufferers interested given the possibility that even their interest in everyday activity may be significantly diminished. But utilizing the concept of self-help, e.g. a free will of PTDS sufferers to treat symptoms on their own, this paper clearly marks qualified individuals. In other words, people suffering posttraumatic depression, or those with avoidance behavior who have difficulties to perform everyday activities, should refer to another forms of treatment.

MUD Therapy--From Theory to Practice

Therapeutic MUD specifically dedicated to the people with psychological disorders and phobias seems to be a better solution to treat PTSD compared to non-specialized MUDs. In this case, posttraumatic stress sufferers not only participate in role-playing but also have a chance to discuss their specific problems and effects of role-playing with other sufferers. Like a peer group, individuals can speak freely, which is reinforced by anonymous nature of the Internet (Baym 54), and can receive support from others if they are not successful. While programming or improving the MUD is relatively an easy task, putting it up on the Internet and maintain appears to be an obstacle. There should be an organization that would provide continuous MUD functioning, because the whole idea of the cyber community within the MUD utters its continuous, not discrete, existence. The idea of the Internet being public domain should be supported, and MUDs should be free of charge. Thus, there should be sponsors who take long-term responsibility to finance the enterprise.

Since special therapeutic MUDs are not available yet, PTSD sufferers can use many of the existing generic MUDs. In some cases, generic MUD seems to be a better choice because the number of its users is usually high. For example, Lambda MOO has several thousand users with an average of two hundred people logged in at the same time. Although generic MUD doesn’t have the peer group effect that would be present in the therapeutic MUD, the interactive and collaborative experience here may be highly favorable. Unfortunately, PTSD sufferers cannot achieve positive results immediately after they start participating in the MUD environment. Using MUD is essentially a gradual learning process. An individual first learns the environment and decides whether or not it is likable. Secondly, an individual learns his or her opportunities in terms of developing the character and role-playing. The author’s personal experience indicates that this may be a very long step toward the success in MUD. Finally, an individual role-plays and socializes on a regular basis, which constitutes a core concept of applying MUDs in treatment of certain PTSD symptoms.

Individuals suffering from traumatic social anxiety may train themselves by forcing to actively participate in social MUDs, but role-playing can also be very supportive. An important factor is the patient’s belief that other people view him or her negatively (Dunmore 825; Wells 653). Based upon such beliefs patients tend to think themselves as losers, unreliable, weak, etc. There are specific features of MUD that can be effectively utilized in ‘repairing’ a patient’s system of belief. A MUD participant can describe the character in all possible ways, but typically MUD characters are given the descriptions of mighty and handsome individualities. The MUD itself is built on descriptions that are the only means to represent objects in the text-based virtual realities. Needless to say that good descriptions are usually appreciated by others.

A phobic person by using a verb 'look' can repeatedly read the description of his own character, which will eventually lead to the development of positive beliefs. Assuming that an individual has a type of cognitive connections with his or her character, the cognitive channel, it is expected that the system of beliefs emerged in MUD role-playing will eventually substitute an individual's phobic self-perceptions, which should result in diminishing of the symptoms of traumatic anxiety for social interactions. Certainly, there is a danger that despite good description, a character will not receive positive appraisals. But as it is stipulated early in this paper, a posttraumatic stress sufferer should proceed with using MUD at one's own discretion and should clearly understand the possible outcomes of the treatment. Due to limitations, this paper doesn't provide a classification of possible positive and negative outcomes of PTSD intervention. But such classification is needed, and it is the author's hope that broadening therapeutic implications of computer mediated communication technologies will fasten detailed profiling of therapeutic outcomes.

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