More than Just a Game? Combat-Themed Gaming Among Recent Veterans with Posttraumatic Stress Disorder

Abstract

This article examines recent combat veterans' experiences of “first-person shooter” (FPS) gaming and its relationship to posttraumatic stress disorder (PTSD). Current PTSD treatment approaches increasingly use virtual reality (VR) technologies, which have many similarities with FPS games. To explore these similarities, this article presents six case studies from recently separated veterans in New York City who reported both current PTSD symptoms and regular use of combat-themed FPS games. In open-ended interviews, participants discussed a range of benefits as well as the importance of regulating use and avoiding particular contextual dimensions of gaming to maintain healthy gaming habits. Findings demonstrate the need for more comprehensive study and dissemination of best-practices information about FPS gaming in the context of combat-related PTSD symptomatology.

Background

Exposure-based posttraumatic stress disorder treatments and virtual reality

Current prolonged exposure treatments for posttraumatic stress disorder (PTSD) derive from work pioneered by Wolpe in the 1950s and 1960s. Drawing on theories of reciprocal inhibition, Wolpe¹ saw learned patterns of avoidance and suppression as the principal obstacles to treating anxiety-based neuroses and advocated for behavioral interventions that desensitize subjects to frightening stimuli. Most clinical applications of prolonged exposure for PTSD have involved basic forms of “imaginal” or “abstract” talk therapy in which traumatic events are narrated until their recollection ceases to provoke the same fearful and avoidant responses.² As has been observed in PTSD subpopulations—for example, those based in sexual trauma, childhood abuse, and motor vehicular accident—narrating traumatic events does not always produce the desired emotional response, as some individuals seem to be capable of reliving traumatic experience without the affective confrontation integral to the extinction of fear-based behaviors.

Partly to address treatment-resistant clinical subpopulations that struggle with recall, refuse to engage traumatic memory narratively, or show diminished affective response to doing so,³ researchers have been working to create more affectively charged contexts for the re-experiencing of traumatic memory. Using an array of digital simulations and virtual reality (VR) technologies,⁴ researchers and clinicians have demonstrated the benefits of enhanced immersion in traumatic memories. Increasingly, combat-related PTSD therapies include VR headset displays that respond to patients' head and body movements. Carefully tailored scenarios including various vehicle (e.g., helicopter or Humvee) simulators^5–7 have been developed, and various biometric indicators of anxiety (e.g., heart rate, skin temperature, sweat gland activity, and respiratory rate)⁸ have been coupled with these simulations to assess that degree of desensitization achieved over time with repeat exposures.⁹ Published results across numerous studies indicate that these technologically assisted approaches are efficacious, potentially showing more robust outcomes than conventional psychotherapy and behavioral modification techniques.^10–13

First-person shooters and virtual combat

In recent years, the “first-person shooter” (FPS) genre has claimed roughly 20 percent of the home console market share, with flagship titles, like the “Call of Duty” (Activision, Santa Monica, CA) series, frequently standing as best-selling games of the year.¹⁴ FPS gaming has already found a place in public health research, largely due to its violent nature and contentious role in recent school shootings^15,16 and links to “addictive” or problem videogaming patterns.^17,18 At the same time, FPS gaming has been shown to provide several benefits and learning opportunities at the level of spatial cognition,¹⁹ working memory and planning,²⁰ and social organization and communication.^21–24 In many ways, FPS gaming defies the traditional stereotype of maladaptive antisocial gaming, as the genre has increasingly moved to prioritize social, online competitive play²⁵ involving gamer organizations commonly known as clans.²⁶ The forms of camaraderie and teamwork characteristic of these social uses of FPS games can provide meaningful and intimate forms of social interaction and identity formation.²⁷

Superficially, FPS games and the clinical VR exposure therapies (VRETs) share many similarities, especially given that current combat VRETs (which involve carefully tailored scenarios depending on the nature of the combat-related trauma)²⁸ are adapted from FPS games. Beyond that, however, very little is known about whether informal and unsupervised use of combat-themed FPS games by combat veterans with PTSD may involve some of the same experiences. Given the widespread use of FPS games by active duty personnel and veterans and the endorsement of FPS gaming by the U.S. Department of Defense itself, partly as a training and recruitment tool,²⁹ this study seeks to better understand the range of experiences with FPS gaming among combat veterans living with PTSD. As only half of recent Iraq and Afghanistan combat veterans in the United States with a need for mental health services are estimated to actually seek treatment,³⁰ investigating the informal practices that may bear on mental health represents an important direction for research in veteran populations.

Materials and Methods

To address the potential for commercial FPS games set in realistic contemporary combat arenas to serve as an exposure modality for military veterans with PTSD, this study drew upon a parent study's sample of U.S. combat veterans living in the New York City area who separated from service between August 2008 and March 2012. Case study participants were selected as a subsample of both the larger panel sample (n=269) and a qualitative sample of 50 ethnographic and focus group participants. The six focal participants for this analysis were selected from a group of 11 ethnographic participants in the parent study who had reported ongoing PTSD experiences. Participants for this analysis were selected based on two criteria: they reported at least weekly use of realistic military-themed FPS games and had self-reported severe PTSD symptomatology on at least one of their baseline or follow-up questionnaires. PTSD was assessed using the 17-item PTSD Checklist for Military (PCL-M) measure,³¹ and participants' most recent scores are reported in Table 1. Not all participants reported severe PTSD symptoms (represented by a score of 50+on the PCL-M)³¹ during those most recent follow-ups, but all six had scored above 50 during at least one administration of the PCL-M. The lead author screened potential participants over the phone and scheduled follow-up interviews with each of the six who spoke of serious involvements with FPS gaming after leaving the military.

Table 1.

Participants' Characteristics

Code name	Branch of service	Ethnicity	Age (years)	PCL-M score	PTSD severity	Traumas
Wolverine	Army	African American	33	67	Severe	Loss of unit members, carrying corpses
Forbes	Marines	White	30	51	Severe	Extensive combat, IED
Alberto	Army	Latino	29	41	Moderate	Regular mortar fire on his post
Coqui	Army	Latino	35	49	Moderate	Moral injury, killing enemies
Kevin	Army	African American	40	48	Moderate	Unit involved with civilian casualties
Blue	Marines	African American	32	53	Severe	Combat gunshot wounds

IED, improvised explosive device; PCL-M, Posttraumatic Stress Disorder Checklist for Military; PTSD, posttraumatic stress disorder.

After giving informed consent, participants were administered a life-history interview about videogaming (and FPS games in particular) and experiences of trauma and PTSD. After elicitation of narratives about PTSD and gaming, more focused questions were posed. Parallel questions about the affect associated with different PTSD symptoms (e.g., hyperarousal, sleeping difficulties, avoidance of social situations, aggression/anger, and intrusive memories) and the feelings associated with different forms of videogame play were asked, as were more pointed questions about interaction effects and both helpful and harmful experiences related to the use of FPS combat games.

The interview schedule and parent study survey instruments were reviewed and approved by the host institution's Institutional Review Board, and all participants provided written consent to participate prior to being interviewed. All participant names used here are pseudonyms.

Findings

Overview of results

The principal contribution of this article to PTSD and videogame research is its focus on a set of participant narratives about the use of FPS games while recovering from combat-related trauma. Accordingly, the generalizability of findings is extremely limited, and veterans' experiences as described do not likely represent the full spectrum of experiences related to FPS use in these contexts. After brief introductions to each of the six participants and their military and gaming experiences, participant claims about the perceived value of combat FPS games are presented. More specific questions about the interaction between gaming experiences and traumatic memory are addressed, and this section ends with an examination of the potential harms or more aberrant forms of memory reconstruction that might result from unsupervised or naive use of FPS games by veterans with PTSD.

Introduction to the participants

Participants entered the study with a range of combat experiences and personal narratives about traumatic experiences. All participants were male veterans deployed to Iraq or Afghanistan. Table 1 presents basic demographics and contexts for military trauma. More detailed biographical information is provided in the Appendix.

Returning home: learning to play FPS games as a veteran

For several participants, one of the greatest disappointments experienced upon return was the realization that their combat training was of no further use to society and was, if anything, a liability in the contexts of civilian life. For Wolverine, the sudden loss of access to firearms fit within a broader perception of having returned home to his own city as a socially isolated alien. Videogames, however, offered a means of managing the impulses that resulted in his own short-term institutionalization shortly after return:

Through video games, I get to live my life without going to jail or the crazy house, without anyone being able to pass judgment…I stood for the right to bear arms. I can't bear arms in the city without, I guess, a half a million dollars. So how else can I, you know, use my experiences [than in] video games? We can't fire those weapons. When you're playing with the headphones, you can order your troops. You can't come home to order your spouse and your kids—you can try to but it's not going to work! Most of the time veterans from the current wars, they don't have any escape and then they end up being put in all these different crazy houses, arrested…All we do have is the PlayStation 4 and the Xbox and the PC games, because we have nothing else.

As Forbes explained, one of the hardest things about returning and coping with PTSD was the disjuncture between “doing what only a small percentage of the people in the world can do, and achieving great, wonderful things…and then going back [to a civilian life] and being just a regular guy.” He explained that activities like FPS games served to validate his military identity:

Video gaming definitely helps. I just consider it something that I relate to while I did while I was in the military…Being in the Marine Corps, like everything is a competition and if you don't make like progressive winnings they will kick you out. So I kind of handled that mentality by competing in online computer games.

For Blue, returning to civilian life and encountering FPS games also involved a period of learning how to play FPS games without unwanted affect. When asked if he returned to combat games immediately upon separation, he related a story from his first days as a civilian:

My cousin…who I used to play video games with…brought me back into it. Two days [after returning home] I went to see him. And he's like, “Yo, you crazy too [like I was when I returned home from military service].” He was like, “Okay cool, you want to play?” And then that's when I got back into it. That's when “Call of Duty” was first out you know and it was World War II, and the Sten gun recoil may pull the gun up, and I'm like wow, and then immediately I'm on my feet. That's not real! So I start critiquing and doing the whole technical assault thing and he's looking at me like, “Damn man, it's just a game. Relax!” And I'm like, “You know, you're absolutely fucking right.”

Flashbacks and traumatic memory

One of the principal research questions in this study was whether popular use of combat-themed videogames among individuals experiencing PTSD symptoms could evoke traumatic memories. Although several participants initially replied that gaming had little relation to actual military experience, all our interviewees ultimately shared stories about how their gaming and their service-related PTSD were connected.

After explaining that in the military he had served as a quartermaster who distributed uniforms and other laundry, Alberto suggested that his FPS combat gaming had become a form of relaxation that engaged his love of modern weaponry, particularly light machine guns. As his PTSD experience came to light over the course of the interview, however, it became clear that finding relaxation in FPS gaming had required persistence and effort after the experience of a powerful mnemonic trigger during one of his first FPS gaming episodes as a newly returned veteran:

[After I left the military] I bought my first Xbox. So I'm playing [“Call of Duty”] and something loud happens and I freaked, and threw my controller. I didn't know what the hell just happened! I had headphones on, so when it happened, I dropped my controller. I was like holy crap! And I remember I didn't play that game for a while. I went back to playing these little kid games, games where nothing went boom.

During Alberto's time in theater, his post received regular mortar fire. As a result, Alberto spoke of his “freaking out” when confronted with loud auditory reports, reminiscent of mortar explosions. For the next 2 months, he explained, he avoided FPS games in favor of racing and sports games, particularly after an event with FPS gaming where he started noticing a strange smell, which he later—at a rifle range—realized was the smell of gun powder.

Forbes, a former Marine with two deployments to Iraq and Afghanistan, initially dismissed the interview question about any possible connections between his combat experience and his FPS gaming. When asked if the gaming ever became “more real” because of where he was and what he'd experienced, he replied:

Oh God no, absolutely not. There's such a huge gap between playing the video game and then going out and doing it for real, it's not even close.

However, when asked more about his gaming as a veteran, Forbes recalled an event very similar to Alberto's synesthetic experience with the smell of gunpowder:

I had got a pair of those headphones that have Dolby Surround Sound, and the guy next to me [in the game] had a SAW [M249 squad automatic weapon] as well, and we were both firing up and the actual sound of it was like so realistic that I started smelling CLP [gun cleaner/lubricant]. That's when I had to take the headphones off! It [freaked me out] a little bit. It went off like a bomb. I really didn't use the headset much after that.

When asked about whether FPS games had ever triggered memories of deployment, Coqui was hesitant to reply. Prompted with brief examples from other interviewees about how sounds could serve as powerful reminders of combat, he reminded the interviewer of how personal every PTSD situation is and explained how, for him, it was not sound but geography in contemporary FPS games that could trigger memory. “You know,” he explained, “the thing is not the actual event, but certain kinds of landmarks that will remind me of deployment.” Accordingly, he reported avoiding games with realistic Middle Eastern settings, particularly when playing alone.

For Wolverine, the suggestion that playing “Call of Duty” is “just a game” was anathema. He explained:

Those first-person shooter games are going to take you back to the day where something bad happened. If your convoy was attacked, times we would have to go into bunkers…running in those bunkers is always traumatic. Watching our DHL plane get blown out of the sky—realistic. Watching it happen on a video game, more realistic. Like for instance, when the war started there were some Scuds [missiles] fired over the city of Kuwait, which made us have to get in MOPP [Mission Oriented Protective Posture] level 5 gear, which means all the chemical gear, all the clothes, all the boots and you had to just stand. Now, there is a part in the [“Call of Duty: Modern Warfare”] game where they're in these masks and every time I see that I always think of that. It brings it back and I tell you…I start thinking I'm there.

While Wolverine confided that he played realistic FPS games, he too explained that he had gone through a period of avoiding them in favor of science-fiction themed shooters.

Perceived benefits of FPS gaming

Despite these experiences of discomfort when playing FPS games as newly returned veterans, the participants in this study all described ways in which they learned how to continue playing the games and how their persistence had been rewarded with a range of perceived benefits.

Blue, in an anecdote that might be interpreted as commentary on the gradual extinction of paralyzing fear through repeated exposure to FPS stimuli, explained how he came to “own” the physical side effects of playing and to connect the feelings experienced during gaming and in psychotherapy sessions:

Because of video games, if I'm in a therapy session I'm noticing my breathing rate, my sweating. I became aware of that when I was playing video games because my palms are sweating. Now the controller is getting slippery. The TV is getting brighter because my pupils are dilating. I'm rocking in the chair because my heart is beating faster. I'm pressing the buttons faster. So now that helps me associate the physical symptoms with my game experience. So now it's more like my physical symptoms aren't becoming a burden because…I'm owning the physical symptoms and I'm utilizing them in an effective manner.

While confiding that he was not comfortable with psychotherapy and the pressure to talk about his traumatic experiences, Blue offered a perspective on PTSD recovery not at all unlike the current exposure-based approaches reviewed above. He further suggested a possible progression beyond videogames:

Yeah I mean if you move up [from FPS gaming], paintball would be really good for PTSD because now you are mimicking actual conditions and it's everything but the report and the muzzle flash. You are wearing your gear. You are smelling the environment. You are there and you're reliving it but in a manner that's safe, and eventually it's easier to [control unwanted flashbacks or episodes]. It's not even a switch anymore; it's more of a dial.

For Alberto, abstaining from FPS games lasted several months, until he got a puppy he credited with “helping with my rehabilitation and getting my mind out of Iraq.” Alberto then returned to FPS gaming, which quickly became an important part of his life again, particularly through his involvement in online play with other veterans, an activity that may have helped considerably with the confrontation of social withdrawal and isolation experienced by many experiencing PTSD symptoms.

For Blue as well, playing FPS games with his peers was an important context for feeling socially “normal” again and participating in healthy social interaction:

So you know just sitting there [playing FPS games] cutting ass with each other, making fun of each other and stuff.…It was cool, you know? And I was relaxed with everyone around me.…Like I said, I'm the only one in my generation that enlisted, and now everybody is feeling comfortable around me. I'm feeling comfortable around them. I don't feel looked at, like “Oh no you're playing a shooting game! Are you going to come around here and try to shoot me?” It wasn't any of that. We are just sitting there having a good time and it made me feel normal. I didn't feel like the odd ball or the guy who's about to snap.

Coqui was careful not to overstate the value of videogames in his own PTSD recovery, something he referred to suggestively as a “puzzle” with many pieces. He explained that PTSD led him to avoid certain social settings and relationships, secure housing and financial stability, find the right balance of medications, and engage in psychotherapy. He explained that videogames provided a welcome “distraction,” which he described as an often overlooked way to “lessen the symptoms of PTSD.” This focus on relaxation was often at odds with the approach to PTSD recovery Coqui had encountered at the Veterans Administration (VA):

When you go to this group session [at the VA], they want you to stop thinking about everything else that's going on in your life and they just want you to focus on where it all started. And nowadays psychiatrists aren't even sure what to prescribe you, you know. They want to just give you different medications, what they feel that you should take based on their opinions rather than the actual keywords that you are actually saying to them.

This theme—that recreation, distraction, and escape are all essential components in managing PTSD—ran through most of our follow-up interviews. As Blue commented succinctly: “I believe that more fun, whether that be gaming, ping pong, or smoking cannabis with friends and talking, should be allotted to therapy for PTSD.”

As Kevin explained, however, playing combat-themed games was a form of distraction complicated by its relation to traumatic memories. The therapeutic value in FPS gaming, he suggested, lies partially in its ability to make traumatic realities feel more game-like in retrospect. After sketching a vivid portrait of his Army unit's “gang mentality” when it came to avenging the loss of its soldiers, even at the cost of civilian lives, Kevin clarified:

Someone in my unit dies, it will become the biggest gang. We are killing the building. We don't care who is in it.…They are going to die today. Going back to the video games, believe it or not, it takes your mind off even doing that. It makes it not real. If somebody says it's therapy, I can say that it is because it downplays in your head what went on, and you need that, you know?

Perceived risks and contraindications

Although all six of the participants in this analysis were ultimately concerned to represent FPS gaming as a beneficial practice in the context of PTSD, several suggested ways in which it might provoke negative responses. Alberto, who spoke at length about his own role in organizing online communities of veterans as FPS “clans,” shared a recent story about a veteran who may have “triggered” after a disrespectful interaction with a young civilian player encountered in online gameplay:

I recently recruited [into my online clan] a guy who is old school. He went to the first Gulf War. [While we were playing online,] we had some civilian kid who probably spends his entire day in front of his Xbox. He said, “Oh you guys are trash.” And [the veteran], he turns around. He ate this little kid alive. The little kid just felt so bad.…He never spoke again. I don't know if the game itself triggered him, or the guy triggered him but like you could tell in his voice.…He was like, “Dude, you're doing this in a game. I did this for real! I've had people shoot at me….” He was like going at this kid and after a while like the little kid just did not say a damn word. He just took the tongue lashing he was getting. Then I recruited him [the veteran] into my clan.

Although it is impossible to gauge the impact of an experience like this one upon an individual's own distinct PTSD trajectory, the event represents a cautionary tale, not just about FPS games themselves but about the online, networked contexts in which they're commonly played. Being in conversation with strangers, most of whom have no military experience themselves, opens veterans up to criticisms and forms of perceived disrespect that cannot easily be cordoned off until a player joins a regular group, or “clan,” of sympathetic players.

Only one of our participants, Blue, responded in the affirmative when asked if he knew of any individuals who had experienced negative outcomes related to their gaming. While refusing to provide details, he commented:

I've seen some guys they have some episodes but it wasn't purely from the video game. It was some other factor…. Either hard drugs, alcohol. It wasn't purely the game.

If a conscious engagement with disorienting exposure to the sights and sounds of combat was an explicit part of several participants' accounts, it was not universal. The delicate nature of FPS gaming for some veterans became evident when Coqui requested that the interviewer refrain from asking directly about whether videogames had ever recalled real combat trauma. Asked why such a direct question was upsetting or distasteful, he replied that he was afraid of the power of suggestion and that his gaming might lead to him “reliving [his] deployment.”

Discussion

As is apparent in the case studies related above, realistic FPS gaming has wide-ranging and potentially powerful effects on combat veterans with PTSD. Our participants all recounted visceral reactions to distinct game stimuli, whether visual, auditory, or part of the broader social contexts for play. Almost all of our participants spoke to periods of caution during which they avoided particular game titles, virtual environments, or technologies (such as “surround-sound” headphones) while they were re-establishing their gaming practices as civilians. Accounts of various means of moderating the impacts of games and regulating use suggest the importance of developing informational, best-practices guidelines for the uses of these games among military and veteran populations, especially those who are not accessing formal mental health treatment and have no clinical oversight for their gaming practices. As participants suggested, early experiences with FPS games by those living with PTSD symptomatology are best undertaken in the presence of trusted peers or loved ones and should perhaps be limited in duration, particularly after a triggering event has occurred. Perhaps most important is that combat veterans should be informed that FPS games appear to have the potential to trigger powerful memories of combat traumas or more generalized synesthetic episodes linked to deployment stimuli.

Despite several participants' suggestions of potentially deleterious outcomes emerging from naive use of FPS games by those with PTSD, the overarching experience of FPS gaming for these six veterans was positive and raises important questions about the potential of these games to serve as an informal or adjunct exposure modality. Even without the added immersion effects of VR headsets, moving seats, and weighted toy assault rifles, veterans described either powerful moments of being transported back to the scene of their service or concerted efforts to avoid letting their gaming evoke such powerful reactions. Beyond these more dramatic accounts of re-engagement with traumatic memory, participants also spoke more generally of the camaraderie, skill sharpening, and pure enjoyment and recreation that this style of gaming provided as they navigated both PTSD and the multiple social and psychological challenges of reintegration.

Although this study involved a small case series and was designed to be exploratory, the findings demonstrate the importance that researchers and clinicians attend to the informal mechanisms veterans may be undertaking—sometimes inadvertently—to desensitize themselves to fearful stimuli in their everyday lives. Is FPS gaming simply a poor substitute for treatment avoidant and resistant subpopulations, or might it be a valuable adjunct to VRET and cognitive process training for PTSD? Does exposure to FPS games prior to or during military service precondition a willingness to undertake VRET as a veteran? And, how does FPS exposure potentially impact resilience to trauma or, after the fact, aid or impede the processing and narration of traumatic memory? As Kevin's account about how FPS games helped make the trauma of participating in the wartime murder of civilians somehow less real—or “more like a game”—indicates, the use of FPS games in reconstructing personal identity may follow multiple pathways, some more productive and grounded in reality than others. In light of how little is known about these questions and how significant the stakes, it is the finding of this exploratory study that clinical research should be conducted on FPS gaming among veterans experiencing PTSD symptoms and that this should be done without further stigmatizing a form of violent digital entertainment that may, at least for some within the right contexts, provide far more benefit than harm.

Appendix

Description of participants

Forbes is a Marine veteran whose active duty service involved two tours of duty, one in Iraq and one in Afghanistan, as a heavy machine gunner in an infantry unit. Forbes described a desire to enter the military as a “front line” soldier and how his early experiences of military-themed videogaming helped “add a bit of culture” and a “window into the world” of military service during his youth. Forbes described a relatively normal, middle-class white American childhood in which his military fantasies were at odds with his parents' political and moral views but served to connect him to his grandfather, a WWII veteran who fought during D-Day. Forbes experienced extensive combat during his two deployments and suffered a severe head injury when an explosion rolled his vehicle. He was formally diagnosed with PTSD after his second tour of duty and, almost 5 years later, reported that he was still coping with PTSD and the aftereffects of traumatic brain injury but had stopped all pharmacological interventions for PTSD. Forbes described videogames, and in particular “Call of Duty” games, as an inescapable part of military life: something you did “to pass the time” as a group, whether during active duty service or stateside, while waiting to be deployed.

Wolverine is a U.S. Army veteran who deployed to Iraq in 2003 and had served continuously since, joining the National Guard upon separation from active duty. He described extensive military traumas, returning at several times during his interview to the dead bodies of fallen brothers he had personally carried back from the front lines and the numerous military funerals he had attended. Wolverine's civilian reintegration had been complicated, he explained, not just by PTSD but by a period of institutionalization in a “crazy house” owing to his family's inability to understand who or what he had become during his military service. Throughout his interview, he used the metaphor of alien abduction to characterize the transformation of his old self into something new, alien, and utterly unrecognizable. Wolverine spoke also of the stigma that faces black veterans in particular and the widespread distrust of combat veterans among the African American community, which had made romantic relationships near impossible after his return. A highly seasoned videogamer, he described the various game genres he has played and the centrality of combat FPS games to his military identity, even going so far as to credit videogames with his survival postseparation.

Alberto is an Army reservist of Puerto Rican and Dominican descent who deployed to Iraq in 2008 as a quartermaster, a military specialty responsible for laundry and bathing facilities. Despite his desire to serve in an infantry unit, Alberto found himself well behind the front lines at a time when most of the heavy fighting had subsided. His post was shelled regularly, however, and mortar fire became an almost daily event that kept everyone in a constant state of vigilance, waiting “for the impending storm.” Alberto's unit suffered almost no casualties during his deployment, and he described being skeptical about the symptoms of PTSD when they began to manifest after his return home. At the time of interview he reported being largely recovered from PTSD, although the hypersensitivity to loud “booms” and the potential for normal sounds of the city to “freeze him in his tracks” persisted. Throughout his narrative he spoke of his military unit as his family and of the value of organized FPS gamer “clans” to ease the pain of separation from his military family.

Blue is a former Army infantryman who identified both as a veteran and as a long-time member of the Crips, a predominantly African American street gang dating to the late 1960s. Blue was in treatment for his PTSD at the time of interview and spoke at length about his extensive research in to PTSD and the various treatment approaches he had taken. Unlike other participants, he spoke of a struggle with PTSD that could not be linked solely to his military experience. A violent murder witnessed firsthand at 11 years of age led to numerous further experiences with gang violence and multiple gunshot wounds prior to enlistment, a decision that was presented as an alternative to incarceration or death. A lifelong videogamer who was always drawn to military-themed games, Blue spoke in great detail about the practical benefits of gaming for military personnel and the opportunities they presented during the difficult process of civilian reintegration.

Kevin introduced himself as a former Army fueler, a heavy truck driver who served in Iraq during the interim between the Gulf War and the beginning of Operation Enduring Freedom in the immediate aftermath of 9–11. Already a college graduate at the time of enlistment, Kevin was older than most of our participants and described how he overcame his ignorance about videogames while learning to play FPS games with other military colleagues. He spoke of the constant stress of being a driver of a “giant rolling grenade” but also of the extensive civilian casualties for which his cavalry unit was responsible and the punitive measures brought against anyone who sought to confess his or her war crimes. Kevin's narrative about coping with guilt through drugs and FPS video gaming—which had become a passion in his life—stands as a rich and challenging account resisting easy interpretation in terms of its therapeutic implications.

Coqui, a former National Guardsman who re-enlisted in the Army as active duty and deployed to Iraq, explained that his pseudonym for the study is the iconic frog of Puerto Rico and a token of his ethnic, cultural identity. He spoke of PTSD as a long slow process, resulting from (in his case) the persistent effects of fear and tension rather than singular traumas. Prescribed an antidepressant in the field to help cope with the growing symptoms, Coqui returned home to confront unexpected challenges and PTSD symptoms, a disorder about which he knew very little prior to his diagnosis. Although not initially an FPS gamer, he explained how enlisting was provocation to relearn videogaming, something he had given up by the age of 18 years and a source of relaxation and comfort amid other more formal treatments and approaches that seemed to dismiss the value of enjoyment and pleasure as genuinely therapeutic.

Acknowledgments

This research was funded by the National Institute on Alcohol Abuse and Alcoholism (grant R01 AA020178-01).

Author Disclosure Statement

No competing financial interests exist.