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Abstract

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. The use of virtual reality (VR) in psychotherapy is often called Virtual Reality Therapy (VRT) or Virtual Reality Exposure Therapy (VRET). Citation: McMahon, E. (2017) Virtual Reality Exposure Therapy: Bringing 'in vivo' into the office. Journal of Health Service Psychology, (Spring), 43, 46-49.
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Virtual Reality Exposure Therapy:
Bringing ‘in vivo’ Into the Office
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.
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Virtual Reality Exposure Therapy
Abstract
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,
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Virtual Reality Exposure Therapy
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
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Virtual Reality Exposure Therapy
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
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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
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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
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Virtual Reality Exposure Therapy
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.
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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
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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).
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.
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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
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Virtual Reality Exposure Therapy
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.
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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
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Virtual Reality Exposure 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.
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Virtual Reality Exposure Therapy
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
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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.
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