Shadows of Combat

Representation of Post-Traumatic Stress Disorder in Immersive Media

By Dominique Vyborna 

January 2023

Introduction

Symptoms commonly associated with Post-Traumatic Stress Disorder (PTSD) can be found represented in storytelling throughout history. Where there has been a war, society has acknowledged the struggle of warriors. Even the warriors of Homer’s Odyssey documented “accounts of intense panic and disturbances during and after battle,” (Scott & Stradling, 1994, as cited by Johnson et al., 2021, p. 170). Any examination of PTSD will intersect with the topics of mental health, trauma, and disability, yet the way PTSD is represented in literature, film, and media are often conflicting. Stories about PTSD in news media show the high level of esteem granted to soldiers and war veterans, whereas other mental health disorders are represented in ways that increase stigmatization (Wu, 2016). Despite the esteem shown to combat veterans who suffer from PTSD, common subtopics such as substance use disorder (SUD) and homelessness continue to be portrayed as tragic all-but-certain outcomes in entertainment media and carry stigma that can harm the dignity of individuals suffering from PTSD.

My team grappled with these topics during the narrative writing and making of Shadows of Combat, an immersive virtual reality (VR) prototype created to fulfill the project brief pitched by industry partner and artist Farhad Berahman. The project narrative embodies some of the stereotypes that can be harmful to PTSD sufferers. Due to the ease with which this narrative was created, it caused me to seek to answer the question: How can the immersive nature of VR be ethically utilized to create an artistic narrative that is emotionally compelling and illustrates the day-to-day struggles of someone with PTSD?

In this essay, I will explore areas of ethical consideration which will span topics from law to psychology to human rights. I will review how PTSD and mental disability are represented in news and entertainment media. I will consider the damage that stigma and discrimination can cause for individuals. And in conclusion, I will give recommendations for future development of the Shadows of Combat prototype as an option to be implemented in the final experience. The literature review will cover topics that directly influence and inform societal treatment of PTSD and disability. I will discuss the applicable medical definitions and legal frameworks. Next, I will review representation of PTSD in both immersive and non-immersive news and entertainment media. Finally, I will examine immersive media that has represented mental illness and disability in ethical ways to later assess their creative choices and methods of creation.

Literature Review and Context

Post-Traumatic Stress Disorder (PTSD) is a mental health condition which may develop in individuals following an experience or series of experiences that are threatening or horrific in nature. According to the ICD-11 published by the World Health Organization (2022), the condition is defined by three main characteristics, summarized as:

1. Re-experiencing the event in the present, in the form of vivid intrusive visions/memories, called “flashbacks,” often accompanied by overwhelming emotions or physical sensations,

2. Deliberate avoidance of reminders likely to produce re-experiencing events, and

3. Perceptions of heightened current threat, signified by hypervigilance or enhanced startle response.

Although PTSD can be caused by a vast range of traumatic experiences, this essay will only focus on combat trauma. Symptom onset may occur any time following trauma, potentially beginning months or years after traumatic exposure. In nearly half of diagnosed cases, symptoms will resolve within 3 months of onset (World Health Organization, 2022). Even lacking a formal diagnosis, if PTSD symptoms have a substantial impact on a person’s ability to maintain their daily personal and professional life and these symptoms persist or recur for more than a year then the condition will automatically be classified as a longterm impairment and would be protected under U.K (United Kingdom). law by the Equality Act 2010 (National Association of Citizens Advice Bureaux, 2020) or U.S. law by the Americans with Disabilities Act (US Department of Justice, 2022). In cases of long-term or treatment-resistant PTSD, this impairment will fall under the legal conditions for disability diagnosis. Given problematic representation of mental health disabilities in media, what considerations must be taken to ensure the dignified representation of persons with mental health disabilities, including PTSD? In 2006, the United Nations (UN) drafted The Convention on the Rights of Persons with Disabilities (CRPD). The Convention codifies that the Rights of Persons with Disabilities are human rights, and it “adopts a broad categorization of persons with disabilities and reaffirms that all persons with all types of disabilities must enjoy all human rights and fundamental freedoms” (United Nations, 2006). The UN has created resources and guidance on how to ethically represent disability in the media to actively support the realization of this goal. One major recommendation included in guidance provided by the UN to reduce stereotypes of disability in media, is that it is “vital to include persons with disabilities and their organizations in preparing for any media and communications strategy or event. A common slogan that echoed through the halls of UN Headquarters during the drafting of the Convention was ‘Nothing about us, without us’” (United Nations, 2019). 

In the article US Media Representation of Post-Traumatic Stress Disorder: A Comparative Study of Regional Newspapers and National Newspapers, author Lu Wu analyses how PTSD is framed by national and regional news media, either episodically or thematically, and the impact that this framing has had on common understanding of PTSD (Wu, 2016). In the book Trauma Culture, E. Ann Kaplan (2005) skillfully dissects and assesses the impact and ramifications of both collective traumas (such as 9/11) and individual trauma versus the experience of vicarious trauma from graphic descriptions and associated photographs and videos published in news reports. 

From the book Cultures of Representation, I will focus on the essay The Other Body: Psychiatric Disability and Pedro Almodóvar (1988-2011) by Candace Skibba, which covers the qualitative analysis of disability representation in cinema within the context of cultural and sociopolitical systems. I will briefly cover treatment of disability and PTSD by entertainment media (Johnson et al., 2021), before finally exploring positive opportunities including leveraging the power that media creators have to facilitate an increased sense of belonging (Hagerty et al., 1992). 

Goliath: Playing with Reality (Anagram, 2021) and Witness 360: 7/7 (East City Films, 2015) are two immersive media experiences which cover the topics of mental health and PTSD in sensitive and positive ways which I will define before revisiting these works in further depth. I will look to these for examples of dignified disability representation in immersive media.

Discussion

Our prototype, Shadows of Combat, was developed in alignment with the project brief from industry partner Farhad Berahman, to create an immersive VR application that demonstrates the experience of PTSD flashbacks – the sense of “living in two worlds simultaneously” – to those who have not encountered it. Our team wanted to represent PTSD in a way that would fulfill both ethical and legal considerations (Fig. 1), and we performed initial research on combat trauma to inform our narrative writing process.

During storyline development, our team explored the statistics in the U.S. and the U.K. on PTSD among combat veterans. Stevelink et al. (2018) reported that among U.K. veterans, probable post-traumatic stress disorder occurred in 6.2% and alcohol misuse occurred in 10.0% of military personnel overall. Combat deployment in Iraq or Afghanistan for ex-serving military personnel showed a PTSD rate of 17.1%; much higher than the rate of 6.1% for currently serving personnel. This higher rate may be explained due to:

“a minority of personnel who leave the Services experience hardship in a range of life domains such as homelessness, financial difficulties, psychological difficulties, substance misuse and lack of social support. It is possible that, for some, the transition from military service to civilian life triggers additional stresses that can have a negative impact on mental health. In addition, personnel may be more reluctant to disclose their symptoms during service, as they may fear being stigmatised or the possibility of negative occupational consequences should they report mental health symptoms,” (Stevelink et al., 2018).

In the United States, Schnurr (2014) found that “the lifetime prevalence of PTSD among Veterans is 7%. Lifetime prevalence was higher among female Veterans (13%) than male Veterans (6%).” Co-occurring substance use disorder (SUD) is present in 46.4% of individuals with lifetime PTSD (Pietrzak, R. H., 2011 as cited by U.S. Department of Veteran Affairs, 2014). Additionally, hazardous drinking is a risk factor for homelessness among veterans. Ghose et al. found that “Transitioning to hazardous drinking more than doubled the risk of homelessness,” (2013). 

With these statistics and PTSD symptoms in mind, our team created a narrative about a male Veteran who returns home with PTSD, to a nice apartment and a return to apparent “normalcy” and the community he had once called home. The protagonist’s inner thoughts are narrated aloud for the immersant to experience, which highlights the grief and shame the protagonist experiences at not being able to reconnect with the society he had left behind. The struggle of reckoning with who he was before the war, the actions he had taken during the war, and coming back as a person fundamentally changed following these horrific experiences eventually exacerbate his PTSD symptoms and the story ends with our protagonist becoming a homeless alcoholic. 

An added ethical risk of representing trauma in a way that is realistically graphic in nature is the risk of causing trauma symptoms in viewers. News media images of war and traumatic circumstances may result in vicarious trauma, similar to the secondary trauma that therapists experience when listening to patients describe their trauma in detail (Kaplan, 2005, p. 87). Kaplan (2005, p. 87) posits that vicarious trauma may lead to one of two outcomes: It may prompt people to confront the cause of trauma, or it may cause people to become avoidant of traumatic topics. In the creation of Shadows of Combat, we determined that we have a duty of care to not cause secondary trauma for immersants. In choosing imagery for flashback scenes, our team deliberately chose to avoid graphic depictions of violence. Instead, we chose to represent the emotion and neurological dysregulation behind flashbacks through sounds and lighting.

While creating this experience, I began to deeply consider the ethics of the “slippery slope” narrative we had created and the impact that it could potentially have on survivors of trauma and the stigma that could be perpetuated in society by the use of its stereotypes. The linear nature of this PTSD-to-homelessness narrative ignored the as-lived experiences of many people with PTSD. I was acutely aware that we had not involved the voices of the community in the development of a richer and more nuanced storyline. Unfortunately, the prototype itself had already been completed and we were unable to update it after taking more time to understand disability in the context of systemic forces such as the stress of transitioning from military to civilian life, associated financial difficulties, stigma, and lack of social support while navigating these life changes. However, I am continuing to explore these topics for use in future projects and to inform potential future development of Shadows of Combat. I will dedicate the rest of this essay to exploring the nuances of ethical disability representation which I discovered post-production. 

The representation of PTSD in regional vs national news media differs in several ways which can influence public perception. In 2016, author Lu Wu analyzed how PTSD is framed by national and regional news media, assessing whether framing is episodic or thematic, and found that national newspapers were more likely to frame PTSD thematically, which highlights issues of political or systemic concern, while regional papers focused on episodic framing by highlighting the individual experience of PTSD sufferers. Wu (2016, p. 230) reports that the use of episodic framing plus sensationalism may result in readers failing to understand the systemic issues surrounding PTSD in regional reporting. On a positive note, the most common subtopic reported among national newspapers – and second most common among regional newspapers – is coping and/or recovery (Wu, 2016, p. 230).

Entertainment media takes a slightly different approach to both PTSD and mental illness. Historically, villains have been portrayed using stereotypes of mental illness, including PTSD, perhaps most notably the Joker from the Batman franchise (Johnson et al., 2021). However, PTSD appears in many fictional heroes and supporting roles as well, such as Tony Stark from the Iron Man series in the Marvel Universe, Marlin from Pixar’s Finding Nemo; PTSD is also featured in many films representing combat veterans, such as Apocalypse Now (Francis Ford Coppola, 1979), Jacob’s Ladder (Adrian Lyne, 1990), and Taxi Driver (Martin Scorsese, 1976) (Johnson et al., 2021). The representations of PTSD in many of these films connect the expression of this disorder to flashbacks and a sense of “madness” in the present moment while also revisiting a moment of the painful past. This highlights a fractured self-identity, from a moment in which the soldier had no choice in their experience of trauma and may now experience a drive to attain a fixed-self to regain a sense of autonomy (Johnson et al., 2021, p. 172-175). Although this may be an accurate representation of many cases of PTSD, there is still a sense that the focus is on the marginalization of the PTSD sufferer as abnormal, causing a dynamic in which a sense of belonging cannot be created.

One of the intentions of disability studies is to examine and highlight the socially constructed concept of normality. The delineation between what is ‘normal’ and what is ‘different’ is primarily created through entertainment media and advertising, and the pressures of capitalism seek to standardize the human body to facilitate consumption (Fraser et al., 2016, p. 159). An outcome of these pressures is the stigmatization and ‘othering’ of disabled persons as ‘abnormal.’ This highlights the ethical responsibility of media creators to represent disability in a way that does not alienate persons with disabilities and instead ethically represents them in a way that normalizes the nuances of life and widens the range of normalcy to affirm the human need for a sense of belonging in all people. In Cultures of Representation, Skibba states that their “analysis suggests that in many ways the films that include mental illness as simply a way of living and a ’normal’ part of human existence are able to break down stereotypes and create a new normal,” ((Fraser et al., 2016, p. 163). 

From this foundation, we begin to understand the power that media creators wield. To be responsible for shaping public opinion around disability, a new possibility becomes apparent: The production of positive, honest, and accurate media representations of persons with post-traumatic stress disorder which create an opportunity for PTSD sufferers to experience a sense of belonging in their communities.

Sense of belonging is defined by Hagerty et al. (1992, p. 173) as “the experience of personal involvement in a system or environment so that persons feel themselves to be an integral part of that system or environment.” A further note derives two defining attributes of sense of belonging, being:

1) The person experiences being valued, needed, or important with respect to other people, groups,

objects, organizations, environments, or spiritual dimensions; and

2) The person experiences a fit or congruence with other people, groups, objects, organizations,

environments, or spiritual dimensions through shared or complementary characteristics.

Additionally, there are three antecedents, or conditions, which must be present before a sense of belonging can occur. They are: 1) energy for involvement, 2) potential and desire for meaningful involvement, and 3) potential for shared or complementary characteristics (Hagerty et al., 1992, p. 174).

I assert that immersive media creators can incorporate representation of these attributes to give people who have previously experienced feelings of stigmatization and alienation access to a sense of belonging. Goliath: Playing with Reality is an immersive animated experience that documents the lived experience of a young man as he is diagnosed with schizophrenia, navigates years of psychiatric institutionalization, and eventually gains the ability to live independently and reconnect to community through multiplayer online videogames (Anagram, 2021). Witness 360: 7/7 is a 360-degree video documentary of the personal experience of Jacqui Putnam, a survivor of the July 7th, 2005, London suicide bombings in which 52 people were killed by Islamist extremists. The director of the film, Darren Emerson, stated that he “was deeply conscious of the responsibility (he) had to tell Jacqui’s story in a way that would honour not only her integrity but also the lives of everyone affected by this tragic event. The goal with the film was to take a global event like the London 7/7 Bombings and offer a new narrative that focused on the emotional journey of one person,” (East City Films, 2015). Goliath and Witness 360: 7/7 both exemplify the CRPD’s principle that including the voices of disabled people helps ensure their dignified representation in media.

Conclusion

In creating immersive media representing the topics of mental illness, disability, and PTSD, several major areas of ethical concern come into focus. As these topics are explored, it becomes apparent that simply reducing harm is not enough. In order to appropriately respect the power that immersive storytellers have, we must seek to include the voices of individuals from the communities we are representing. We must be aware of systemic factors which may complicate PTSD outcomes, such as sociopolitical structures and cultural context. These must be taken into consideration and be incorporated into the narrative to thematically frame the topic of PTSD from combat trauma with the purpose of highlighting a need for systemic change. The fractured identity and alienation that accompany PTSD reduce the sufferer's ability to connect with others and find a much-needed sense of belonging. Immersive storytellers can utilize game elements to increase sense of belonging in immersants or to model sense of belonging as an aspect of healing within narratives. 

For the future development of the Exploring the Shadows narrative, I recommend incorporating several other characters, to model a social support structure that will ultimately be key to the main character’s recovery. Include conversations or interactions where the main character experiences symptoms, such as flashbacks or emotional dysregulation, and through social interaction and willingness to be authentic, the symptom passes more quickly. If it is determined that a PTSD-to-homelessness narrative would still be the most powerful artistic choice, I strongly recommend continuing the narrative to deliberately demonstrate that there is a way out of these difficult circumstances. Through community, healing can be created.

The major take-away is that representing PTSD as “not normal” furthers the ableist and stigmatizing narratives in society around this disability. By writing a narrative that creates relatability, emotional connection, and nuanced daily moments with PTSD symptoms operating in the background, we can create an opportunity to normalize this condition in society and allow combat veterans to experience the healing power of a sense of belonging in their communities.

Media has the ability to influence culture and social norms, and creators of all forms of media have a responsibility to represent disability in a way that reduces stigma thus creating a pathway for individual human beings to come back to the campfire of humanity.

Dominique Vyborna is an Entrepreneur and Researcher in the intersection of Virtual Reality, Culture, Innovation, and Digital Therapeutics. For collaboration: dominique@empressvr.com

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