Elizabeth McMahon, PhD
Author Footnote: Elizabeth McMahon, PhD received free equipment from Psious as a beta tester and speaker honorarium for a 10-week webinar for Psious. She is on the Advisory Board of Limbix Health.
Exposure is a critical element in the successful treatment of phobias and anxiety disorders. Virtual reality offers the most efficient means of providing exposure in such treatment. Virtual reality exposure permits controlled, individualized, and repeatable exposure that might otherwise be difficult or impossible. Research and meta-analyses have demonstrated that virtual reality exposure therapy is effective and that the effects transfer to the real world and are maintained.
There is a broad general consensus that exposure is a critical component in effectively treating phobias and anxiety disorders (Beck, Emery & Greenberg, 1985). It is less clear which methods are best to achieve that exposure and process the experience. Should you be with the patient during the exposure experience, or can you simply encourage them to do exposure on their own between sessions? Is it important to have standardized exposure experiences across patients with similar difficulties or do exposure experiences need to be tailored to the individual? How do you choose the exposure for optimal therapeutic success and compliance? What are the advantages and limitations of current exposure options, including virtual reality? Is exposure using virtual reality effective? What factors should be considered in deciding whether to use virtual reality in the office for exposure?
Wolitzky-Taylor and colleagues (2008) performed a meta-analysis of 33 randomized treatment studies of the efficacy of psychological treatments for specific phobias. They concluded that the data clearly support the “…superiority of exposure-based treatments over alternative treatment approaches for those presenting with specific phobia” (p. 1022) and, further, that type of specific phobia was not a moderating factor. In a meta-analysis of 13 functional brain imaging studies with a total of 327 persons with specific phobia, Ipser, et al. (2013) found exposure-based therapy resulted in changed activation in areas of the brain consistent with our knowledge of the neuroanatomy of fear conditioning and extinction. So, we know exposure effectively treats specific phobias, but how is exposure best delivered?
Two general approaches are used in providing exposure therapy for phobias. One approach is implosion therapy (also known as flooding or implosive therapy). This technique involves prolonged exposure at high fear intensity with the goal of speedy extinction of the fear response (Stampfl & Levis, 1967). This is the ‘jump in the deep end of the pool’ approach. It can be effective, but can cause intense patient distress and may be difficult to convince patients to tolerate. The other approach involves gradually increasing exposure with the goal of titrating the intensity of patient response, beginning with phobic stimuli which trigger no more than mild-moderate distress, reducing or extinguishing the fear response before exposing to more intense triggering stimuli (Wolpe, 1990). This approach is often paired with cognitive therapy and anxiety management techniques.
Standard approaches to providing exposure include imaginal exposure done in session or as homework, in vivo exposure in the office if it can be arranged, accompanied in vivo exposure outside the office, and assigned in vivo exposure homework to be done by the client between sessions. Exposure that is done in-office lets the therapist monitor patient response. Advantages of imaginal exposure are that it can be done in-office or at home, and requires no props. In vivo exposure, whether in-office, accompanied outside the office, or done alone by the patient as homework is more vivid—and, obviously, more “real.”
While the above options can be effective, each has limitations. With imaginal exposure, you cannot control content or intensity. Even with guided in-office imaginal exposure, you cannot “see” what your patient is imagining. Furthermore, people vary in their capacity to vividly imagine, and vividness of visual imagery declines with age (Grenier et al, 2015), so patients may be unable to create effective images. In-office exposure requires bringing phobic stimuli into the office and options for that are limited. While some exposure can be performed using pictures and/or YouTube videos or movie clips, you must find relevant materials and, even after you find them, you cannot change the content to titrate exposure intensity. Arranging therapist-accompanied out-of-office in vivo exposure is sometimes possible, for example, riding a public elevator or driving, but access to phobic situations is not always easy or convenient. Plus, doing exposure therapy in public settings raises issues of patient privacy and confidentiality. The last option, assigning exposure as client homework, leaves the patient to face phobic stimuli without therapist guidance, support, or monitoring. Patients may be reluctant to do in-vivo exposure on their own and, on a practical level, many exposures are challenging or even impossible to arrange in real life. For example, neither you nor your flight-phobic patient can arrange for repeated airplane takeoffs. So, this raises the question “is there a better way to offer exposure?” Proponents of virtual reality exposure therapy (VRET) say the answer is a resounding “yes.”
In VR, the patient wears a headset, sometimes called a head-mounted display, which creates a completely 3-dimensional, immersive virtual environment (VE). The patient is “inside” the VE and does not see the outside environment. The patient’s view changes as s/he looks around. Appropriate sounds are programmed, making the experience more realistic. On your computer monitor, you see what the patient sees, and you control various aspects of the VE that the patient experiences. For example, in a fear of public speaking VE, you can control the setting, audience size, and audience response. Sometimes tactile stimuli are added via a vibrating platform or props (i.e., a machine gun for VRET for war-related PTSD) and/or olfactory stimuli using scents. A variant of VR, Augmented Reality (AR), superimposes virtual objects on the real world—think Pokemon. An example of AR for spider phobia might involve looking through the phone at your desk (as if you were about to take a photo of it) and seeing your actual desk but also seeing a “virtual” spider on the desk.
Using virtual reality (VR) to provide exposure is evidence-based and offers many advantages. A meta-analysis of 23 studies of virtual reality exposure therapy (VRET) found that it is effective and well accepted by patients (Opris, et al., 2012). Additionally, in a study of 265 exposure sessions, Robillard, et al. (2011) concluded that exposure in VR is less burdensome and more adaptable to patient needs than in vivo exposure. It is easier to arrange and control. Using VR, you can offer individualized, controlled, graduated, immediately available, infinitely repeatable exposure in the office. You can monitor, support, guide, and prompt the patient during exposure. Offering VRET not only meets patient needs, but differentiates your practice or agency in a positive way and highlights that you offer cutting edge, evidence-based services consistent with best practices. Increasingly, potential patients seek me out because they are specifically looking for VRET. Finally, demonstrating VRET to physicians and behavioral health professionals (and discussing its benefits and effectiveness) results in referrals.
Using VR, you can offer individualized, controlled, graduated, immediately available, infinitely repeatable exposure in the office.
VRET has few disadvantages. Occasionally a patient may experience nausea, but this has decreased with increases in computer processing speed, and, in my experience, is now rarely a problem. Because patients with a history of seizures are usually excluded from studies of VRET (i.e., Anderson, et al., 2013), the clinician may wish to consider medical referral before beginning VERT. Reassuringly, research shows that concerns that VRET might interfere with the treatment alliance are unfounded (Ngai, Tully, & Anderson, 2015).
Krijn and colleagues (2004) reviewed the research literature and concluded there was strong evidence of VRET’s effectiveness for fear of heights and fear of flying. Parsons & Rizzo’s (2008) meta-analysis of 21 studies found that VRET was increasingly being used for anxiety and specific phobias and resulted in significant symptom reduction. A meta-analysis by Opris, et al. (2012) concluded that VRET for anxiety disorders was as effective as standard, evidence-based intervention, that results transferred to real-life, and that treatment gains were maintained over time. In a randomized control trial of VRET for social anxiety disorder where public speaking was the primary fear, Anderson, et al. (2013) found that significant improvement occurred and was maintained at 12-month follow-up. And in a randomized controlled trial of CBT comparing VR exposure, in vivo exposure, and waiting list for social anxiety disorder focusing on anxiety in social situations, not just public speaking anxiety, Bouchard, et al. (2016) found that VR exposure was cost-effective, practical, efficient, and both easier and more effective than in vivo exposure.
How You Get Started
The two companies currently developing and selling VR software designed for use in psychotherapy are, listed alphabetically, Psious (www.psious.com) and Virtually Better, Inc. (www.virtuallybetter.com). They each offer manuals for self-guided training as well as individual or group training in person or online. Continuing education workshops on VRET are starting to be offered, like the half-day workshop at the 2016 APA convention and 90-minute workshops at the California Psychological Association convention in 2016 and 2017. You might also read Advances in Virtual Reality and Anxiety Disorders, edited by Wiederhold and Bouchard (2014).
. . . simple exposure without effective skills can also result in increased fear and decreased hope.
Each company offers different products and has different pricing structures. What you purchase depends on the clients you see, the issues you treat and, to some extent, your budget and office space. Psious has virtual environments (VEs) for agoraphobia, claustrophobia, flying phobia, generalized anxiety disorder, heights phobia, social anxiety, and test anxiety and for fears of cockroaches, darkness, driving (city, highway, bridge, tunnel), needles, public speaking (small to large audiences and settings), and spiders. Other VEs are designed for skills training in diaphragmatic breathing, mindfulness, and progressive muscle relaxation. Augmented reality and/or videos for some of the above uses are also included. There are options to trigger sounds of hyperventilation or increased heart rate (for interoceptive exposure) or to play pre-recorded audio instructions for relaxation during VE exposure. The Psious VEs run on a Samsung Gear VR headset and Samsung android phone which you can purchase yourself or from Psious. The Psious VEs can be run with the dialog in Spanish as well as English which may be of interest to psychologists working with bilingual or monolingual Spanish-speaking patients. This Spanish is “Spain” Spanish, not Puerto Rican or Mexican Spanish.
Virtually Better, Inc. (VBI) has a set of VEs for treating phobias that includes flying, heights (bridge, tall building), public speaking, spiders, and storms. VBI’s VEs give the patient a handheld controller as well as a headset. The handheld controller lets patients control movement in the VE which may decrease the chance of nausea. The VEs can run on iPhone or android phones which you can purchase yourself or from VBI. To use either company’s products, you need a reliable internet connection for your computer and Wi-Fi connection for the phone. The headset and phone from either vendor (as well as VBI’s controller) are all small enough to lock up in a desk drawer—and should be locked up. There have been instances of psychologists having their VR headset and phone stolen.
VBI also sells separate sets of VEs for skills training (autogenic training, diaphragmatic breathing, imagery-guided relaxation, mindfulness, and progressive muscle relaxation), for addictions (exposure to cues for alcohol, drug, and tobacco use), and for war-related PTSD (Virtual Afghanistan and Virtual Iraq). More equipment and space are needed for these sets of VEs. They currently require a separate PC on a rolling cart with 2 monitors and optional additional equipment as well as the headset, phone, and controller.
With the widespread adoption of smartphones and the recent availability of affordable VR headsets, multiple VR apps are being developed and marketed, such as apps for learning diaphragmatic breathing, relaxation, or mindfulness, apps for mood tracking, and apps for completing homework forms. VR apps are also being actively developed for self-treatment of various conditions, including phobias and fears. Some patients may benefit from using these either for self-help or as adjunctive tools supporting their work in therapy. At the same time, the pressure to bring products to market quickly and promote them widely to the public means that, with the best of intentions, overblown claims may be made for the safety and efficacy of these self-treatment apps in advance of research evidence. It is certainly true that exposure is required to overcome a fear and I am sure some users will benefit, but simple exposure without effective skills can also result in increased fear and decreased hope. If just facing one’s fear was sufficient, every person with public speaking anxiety, fear of flying, or driving phobia would be free of fear after giving a speech, riding a plane, or driving a car—and we know that is not the case. My hope is that these apps will contain cautionary statements, as self-help books do, that using the app is not a replacement for therapy. VR is a tool, not a treatment.
How to Introduce the Service into Your Practice
If you already treat anxiety disorders or subclinical fears or worry and you incorporate some form of exposure, it is easy to add VR exposure. Similarly, if you teach relaxation skills or mindfulness, introducing adjunctive skills training to your practice using VR should go smoothly. The therapist controls are fairly intuitive, but you will want to spend some time familiarizing yourself with the various environments and variables. Patients are intrigued by VR and find the experience quite engaging. Although each VE or set of VEs was designed for specific fears, VEs designed for one anxiety disorder or one purpose can often provide relevant exposure for other anxiety disorders. For example, a VE for fear of the dark may provide relevant exposure when treating someone with PTSD after being assaulted in the home or whose worries or compulsions to check increase at night. The VE of being in an MRI, although designed for claustrophobia, may provide relevant exposure for patients with illness anxiety. Patients with OCD who have contamination fears may respond to VEs of planes, public transit, cars, or hospital waiting rooms. The “relaxation” VE of floating under the sea may provide exposure for patients with claustrophobia or fear of water. The VEs for social anxiety may help patients with Autism Spectrum Disorder or schizophrenia prepare for job interviews or improve social skills.
Practical Issues Involved with VR Therapy
There is no special billing code for VRET. Therapy sessions in which you use VR are simply billed as therapy. The psychologist may consider having patients with a history of seizures medically cleared by their primary healthcare provider prior to VR, but special evaluation for VR exposure is otherwise not necessary. In my informed consent, I discuss that treating anxiety involves exposure (facing the fear—in imagination, in virtual reality, and/or in real-life), briefly review the treatment approach, its rationale and effectiveness, and what patients can expect. And, I reassure the patient that we always work together with their permission.
Patient appropriateness for VR exposure is evaluated by answering the following questions. Do they have anxiety tolerance and/or distress tolerance techniques? Do they understand the treatment rationale? Do they consent? Do they have the skills to benefit from exposure? Have relevant fears and contributing core beliefs been identified, articulated, and effectively countered? Throughout exposure, I monitor patient response by observing, asking their anxiety level 0-10 (SUDS), and sometimes recording galvanic skin response. I actively prompt or model the use of skills. If a patient becomes too anxious, variables of the VE can be adjusted to reduce anxiety-provoking stimuli, or exposure can be shortened, paused, or stopped. VR exposure may uncover previously unidentified fears, allowing them to be addressed in therapy. Successful response to VR exposure increases the patient’s self-efficacy and hope. It helps confirm that the patient has effective skills and can use them.
Nausea, as noted earlier, is infrequent, but if it occurs, you can shorten exposure duration, have patients use diaphragmatic breathing to reduce queasiness, or have them close their eyes during VR stimuli that cause nausea. It is usually during “movement” in VR when patients experience mixed sensations, because their visual input shows them as moving, but their proprioceptive input tells them that they are not moving. Nausea is less common with recent changes in VEs, with videos, and/or when the patient controls his/her movement in the VE.
No specific best practices for VR have been developed. One should follow usual best practices and ethical guidelines. Relevant ethical standards include privacy and confidentiality (minimizing intrusions on privacy, disclosures, and use of confidential information for didactic purposes) and advertising and other public statements (especially subsections on testimonials and media presentations). An ethical advantage of VRET is that you can do “in-vivo”-like exposures without leaving the office.
Do not use your personal phone in the headset to display VR if patient information would then be kept on your phone. If you log on to a website to control the VR software, do not put information on the website that would identify your patient unless the website is HIPAA-compliant, you have a BAA with them, and patient PHI is protected. Be sure to sufficiently obscure patient details when writing or presenting. Avoid practicing across jurisdictional lines. Only practice in states where you are licensed. And, of course, obtain consultation regarding legal or ethical questions or concerns.
In summary, exposure using virtual reality is evidence-based with research supporting its effectiveness. The equipment and software are increasingly affordable, compact, and easy to use. Technical support is available. Virtual reality therapy is acceptable to patients, and patients respond emotionally and physiologically to the virtual environments. Decreases in anxiety which occur in VR generalize to real life situations and are maintained at follow-up. VR permits a level of evocative, controlled, individualized, repeatable exposure that is otherwise often difficult or impossible. It is easily combined with current effective treatments and is rapidly showing promise to aid in treating most, if not all, anxiety disorders.
Elizabeth McMahon, PhD, is a psychologist in private practice in San Francisco, CA. She has over 30 years of experience practicing psychotherapy, supervising, teaching, and writing. She has used virtual reality in treating anxiety disorders since 2010 and is writing a therapist manual on incorporating virtual reality in therapy.
Anderson, P.L., Price, M., Edwards, S.M., Obasaju, M.A., Schmertz, S.K., Zimand, E., & Calamaras, M.R. (2013). Virtual reality exposure therapy for social anxiety disorder: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 81, 751-760.
Beck, A.T., Emery, G., & Greenberg, R.L. (1985). Anxiety disorders and phobias: A cognitive perspective. New York, NY: Basic Books.
Bouchard, S., Dumoulin, S., Robillard, G., Guitard, T., Klinger, É., Forget, H., Loranger, C., & Roucaut, F.X. (2016). Virtual reality compared with in vivo exposure in the treatment of social anxiety disorder: a three-arm randomised controlled trial. The British Journal of Psychiatry, bjp.bp.116.184234. http://doi.org/10.1192/bjp.bp.116.184234
Grenier, S., Forget, H., Bouchard, S., Isere, S., Belleville, S., Potvin, El., Rioux, M-E. & Talbot, M. (2015). Using virtual reality to improve the efficacy of cognitive-behavioral therapy (CBT) in the treatment of late-life anxiety: Preliminary recommendations for future research. International Psychogeriatrics, 27, 1217-1225.
Ipser, J.C., Singh, L., & Stein, D.J. (2013). Meta‐analysis of functional brain imaging in specific phobia. Psychiatry and Clinical Neurosciences, 67, 311-322.
Krijn, M., Emmelkamp, P., Olafsson, R., & Biemond, R. (2004). Virtual reality exposure therapy of anxiety disorders: A review. Clinical Psychology Review, 24, 259-281.
Morina N, Ijntema H, Meyerbröker K, Emmelkamp PM. (2015). Can virtual reality exposure therapy gains be generalized to real-life? A meta-analysis of studies applying behavioral assessments. Behaviour Research and Therapy. 74,18-24. doi: 10.1016/j.brat.2015.08.010. Epub 2015 Aug 31.
Ngai, I., Tully E., & Anderson, P. (2015). The course of the working alliance during virtual reality and exposure group therapy for social anxiety disorder. Behavioural and Cognitive Psychotherapy, 43, 167-181.
Opris, D., Pintea, S., Garcia-Palacios, A., Botella, C., Szamoskozi, S., & David D. (2012). Virtual reality exposure therapy in anxiety disorders: A quantitative meta-analysis. Depression and Anxiety, 29, 85-93.
Parsons, T.D. & Rizzo, A.A. (2008). Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: A meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry, 39, 250-261.
Price, M., Mehta, N., Tone, E.B., & Anderson, P.L. (2011). Does engagement with exposure yield better outcomes? Components of presence as a predictor of treatment response for virtual reality exposure therapy for social phobia. Journal of Anxiety Disorders, 25, 763-770.
Stampfl, T.G. & Levis, D.J. (1967). Essentials of implosive therapy: A learning-theory-based psychodynamic behavioral therapy. Journal of Abnormal Psychology, 72, 496-503.
Wiederhold, B. K., & Bouchard, S. (Editors). (2014). Advances in Virtual Reality and Anxiety Disorders. Springer Science + Business Media.
Wolitzky-Taylor, K.B.; Horowitz, J.D.; Powers, M.B.; & Telch, M.J. (2008) Psychological approaches in the treatment of specific phobias: A meta-analysis. Clinical Psychology Review, 28, 1021-1037.
Wolpe, J. (1990). The practice of behavior therapy (4th edition). New York, NY: Pergamon Press.