Conference PaperPDF Available

Engineering a Showcase of Virtual Reality Exposure Therapy


Abstract and Figures

Numerous research studies and controlled trials have unveiled the potential of serious games in various health-related areas [1]. Their range of application can be even further extended by the use of virtual reality (VR) technology, which allows the realistic representation of interactive contents. Virtual Reality Exposure Therapy (VRET) is a very promising novel use case for the development of serious games. Held in a virtual environment (VE) adaptive to the needs of the patient, this form of therapy can outperform traditional realworld measures [2], [3]. One of its major success factors is the engagement of the patient, which can be increased by an immersive gaming experience. We show a demonstrator of VRET application for a fire-related post-traumatic stress disorder (PTSD). In this demonstrator, features to support actively guided VR experiences are improved on, focusing on the interactive adaptivity of the VE.
Content may be subject to copyright.
Engineering a Showcase of Virtual Reality Exposure Therapy
Andreas M¨
uller1, Samuel Truman1, Sebastian von Mammen1and Kirsten Brukamp2
1University of W¨
urzburg, 2Protestant University Ludwigsburg
Abstract Numerous research studies and controlled trials
have unveiled the potential of serious games in various health-
related areas [1]. Their range of application can be even
further extended by the use of virtual reality (VR) technology,
which allows the realistic representation of interactive contents.
Virtual Reality Exposure Therapy (VRET) is a very promising
novel use case for the development of serious games. Held
in a virtual environment (VE) adaptive to the needs of the
patient, this form of therapy can outperform traditional real-
world measures [2], [3]. One of its major success factors is
the engagement of the patient, which can be increased by
an immersive gaming experience. We show a demonstrator
of VRET application for a fire-related post-traumatic stress
disorder (PTSD). In this demonstrator, features to support
actively guided VR experiences are improved on, focusing on
the interactive adaptivity of the VE.
In exposure therapy, an experienced therapist exposes
the patient gradually to stimuli that induce his pathological
fears. By this means he can reflect his undesired behavioral
patterns and develop effective countermeasures [4]. Lack of
accessibility and adaptability of fear-inducing stimuli is this
therapy’s major disadvantage—consider the fear of flying and
the therapist’s lack of control over an actual airplane [5].
VRET transfers the concepts of the real-world approach to
a VE that can be adapted to the specific needs of a patient.
Over 20 controlled trials have proven that VRET performs
at least as well as its real-world counterpart [6]. Yet due
to the lack of knowledge to build a VR application that
fits their specific needs, therapists largely refrain from using
VRET [6], [7]. The company Virtually Better, Inc. (VBI) is
the market leader in VRET applications. One of their key
features is the interface the therapist uses for controlling the
VE and monitoring the patient. It shows the player’s view,
layout panels with input forms to trigger game events as well
as a separate form to log and make notes about the player’s
health condition. In VBI’s products, some phobia scenarios
are video recorded instead of rendered in real-time, which
reduces adaptability. Although the global game environment
can be modified at run-time with a slider menu, direct control
the parameters of certain stimuli is missing. The therapeutic
interface also lacks a preview mode of intended changes.
User interaction is also limited, e.g. lacking the means to
control one’s movements, to interact with 3D objects, or see
one’s own body. This lack of interaction lowers immersion
which, in turn, lowers the effectiveness of a serious game
A generic therapy cycle underlies all VRET use cases
[9], which we have condensed into the diagram shown in
Figure 1. The therapist continuously identifies, classifies the
stimuli that cause pathological fear according to the sever-
ity of symptoms and perceived threat levels, and controls
them [10]. For VRET, the application requirements reflect
Fig. 1: In VRET, the therapist (a) selects an adequate
stimulus to (b-c) confront the patient. Based on (d) its impact,
the (f) the stage of the fear hierarchy is adapted and/or (g)
the session is stopped.
the needs of the therapist to control the outlined therapy
cycle and of the patient to ultimately be in charge of the
progression of the therapy at his own pace and that game
decisions are made based on his own free will. In addition, he
has to be praised and encouraged to step further [11]. Figure
2 shows the supervision monitor, the interface of the therapist
of our demonstrator of a VRET for fire-related PTSD. It
allows him to interact with the VE and observe the patient’s
situation. Fear-inducing stimuli in the overview at the bottom
are represented as red pins with a preview icon. Clicking on a
pin, a contextual window is opened that allows the therapist
to modify the respective stimulus’ intensity, see Figure 3.
With the help of a preview mode, the therapist can estimate
the possible impact of planned changes before confirming
and actually presenting them to the patient. As shown in
Figure 4(a), the trajectory of the patient’s teleportation is
visualized by a trail of footsteps. He can pick up notes that let
the narrative progress or give him a hint on other interactive
elements. These notes are represented as blue pins on the
floor map and can be highlighted by the therapist. The patient
can observe his heart rate in real-time by a pulse sensor that
is attached to his wrist and represented by a fitness watch
in virtual reality (as shown in Figure 4(b)). The integration
of sensor information serves two purposes: (1) It increases
the degree of immersion experienced by the patient. (2) It
can be used as a therapeutic medium to focus the patient’s
attention on his body signals. This allows him to become
aware of his own sensitive physiological reactions and thus
can help to calm himself [12]. Overall, the design of the
supervision monitor is plain and functional. GUI elements
are sized, placed and colored to be quickly operated also in
stressful situations.
Fig. 2: Top-left: Stream of the patient’s view. Top-center:
The patient’s heart rate and perceived fear level. Top-right:
Adjustment of global parameters. Bottom: VE map with the
patient depicted in pink. Pins represent configurable stimuli.
Fig. 3: The control window of a fire stimulus and its preview
in the context of the floor map.
Based on a comprehensive review on VRET literature and
seminal existing applications, we have systematically ex-
tended the state-of-the-art in terms of interactive supervision,
visual feedback and patient immersion. To this end, we pre-
sented an intuitive and goal-oriented supervision monitor that
serves as the therapist’s interface to observe and control the
course of a therapy-supporting VRET session. The monitor
integrates various supportive technologies such as the real-
time stream of the patient’s view, his contextual tracking
in the VE, integration of additional sensory information for
(a) Footsteps. (b) Virtual fitness watch.
Fig. 4: Visualization techniques in VR for (a) the navigation
system (b) and the heart rate.
both the player and the supervisor (e.g. the pulse tracker),
the ability to directly adjust global system parameters and
concrete stimuli, and to log therapy-critical events. Based
on our results, empirical studies have to be conducted as
next step to reinforce the effectiveness of aforementioned
concepts in practice.
[1] T. M. Connolly, E. A. Boyle, E. MacArthur, T. Hainey, and J. M.
Boyle, “A systematic literature review of empirical evidence on
computer games and serious games,” Computers & Education, vol. 59,
no. 2, pp. 661 – 686, 2012.
[2] L. R. Valmaggia, L. Latif, M. J. Kempton, and M. Rus-Calafell,
“Virtual reality in the psychological treatment for mental health prob-
lems: An systematic review of recent evidence,Psychiatry Research,
vol. 236, pp. 189 – 195, 2016.
[3] S. Bouchard, S. Dumoulin, G. Robillard, T. Guitard, E. Klinger,
H. Forget, C. Loranger, and F. Xavier Roucaut, “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 : the journal of mental science, vol. 210, 12 2016.
[4] A. T. Beck, “Cognitive therapy: Nature and relation to behavior
therapy,Behavior Therapy, vol. 1, no. 2, pp. 184 – 200, 1970.
[5] J. L. Maples-Keller, B. E. Bunnell, S.-J. Kim, and B. O. Rothbaum,
“The use of virtual reality technology in the treatment of anxiety and
other psychiatric disorders,” Harvard review of psychiatry, vol. 25,
no. 3, p. 103, 2017.
[6] P. Lindner, A. Miloff, W. Hamilton, L. Reuterski¨
old, G. Andersson,
M. B. Powers, and P. Carlbring, “Creating state of the art, next-
generation virtual reality exposure therapies for anxiety disorders
using consumer hardware platforms: design considerations and future
directions,” Cognitive Behaviour Therapy, vol. 46, no. 5, pp. 404–420,
2017. PMID: 28270059.
[7] C. P. McLean and E. B. Foa, “Prolonged exposure therapy for post-
traumatic stress disorder: a review of evidence and dissemination,
Expert Review of Neurotherapeutics, vol. 11, no. 8, pp. 1151–1163,
2011. PMID: 21797656.
[8] M. E. Latoschik, J.-L. Lugrin, M. Habel, D. Roth, C. Seufert, and
S. Grafe, “Breaking bad behavior: Immersive training of class room
management,” in Proceedings of the 22Nd ACM Conference on Virtual
Reality Software and Technology, VRST ’16, (New York, NY, USA),
pp. 317–318, ACM, 2016.
[9] L. F. Hodges, B. O. Rothbaum, B. Watson, G. D. Kessler, and
D. Opdyke, “A virtual airplane for fear of flying therapy,” in Pro-
ceedings of the IEEE 1996 Virtual Reality Annual International
Symposium, pp. 86–93, March 1996.
[10] M. Katerelos, L. L. Hawley, M. M. Antony, and R. E. McCabe,
“The exposure hierarchy as a measure of progress and efficacy in the
treatment of social anxiety disorder,Behavior Modification, vol. 32,
no. 4, pp. 504–518, 2008. PMID: 18525064.
[11] B. Wiederhold and M. Wiederhold, “Lessons learned from 600 virtual
reality sessions,” CyberPsychology & Behavior, vol. 3, 06 2000.
[12] P. Francesco, M. G. Mauro, C. Gianluca, and M. Enrico, “The efficacy
of relaxation training in treating anxiety.,International Journal of
Behavioral Consultation and Therapy, vol. 5, no. 3-4, p. 264, 2010.
... VR has proven effective in the field of medicine [17]. But creating a VR experience requires experience in 3D design, interaction design, programming, and considerable time investment, which barres most medical experts from realizing such experiences. ...
Full-text available
Using a complex software system can pose a difficult challenge for its users, especially for those without technical backgrounds. This paper outlines a concept to deploy Recommender Systems coupled with Intelligent User Interfaces as an effective mechanism to guide a user of a complex software system through context-aware suggestions. More concretely, we focus on an authoring tool that our research draws motivation from and will find opportunities for evaluation---it is a platform that aims at empowering medical professionals to create virtual reality experiences to help their work. This paper elaborates on the envisioned concept and the plan for implementation and evaluation.
Conference Paper
The perception of time is closely related to our well-being. Psychopathological conditions such as depression, schizophrenia and autism are often linked to a disturbed sense of time. In this paper we present a novel framework called Metachron, which is intended to support research in the field of time perception and manipulation in Virtual Reality (VR). Our system allows the systematic modification of events in real time along the three main event axes i) Velocity, ii) Synchronicity and iii) Density. Our future work will investigate the influence of each dimension on the passage of time (varying velocity of time flow) and the structure of time (varying synchronicity of events), which should provide insights for the design of VR diagnostic and therapeutic tools.
Full-text available
Background: People with social anxiety disorder (SAD) fear social interactions and may be reluctant to seek treatments involving exposure to social situations. Social exposure conducted in virtual reality (VR), embedded in individual cognitive-behavioural therapy (CBT), could be an answer. Aims: To show that conducting VR exposure in CBT for SAD is effective and is more practical for therapists than conducting exposure in vivo METHOD: Participants were randomly assigned to either VR exposure (n = 17), in vivo exposure (n = 22) or waiting list (n = 20). Participants in the active arms received individual CBT for 14 weekly sessions and outcome was assessed with questionnaires and a behaviour avoidance test. (ISRCTN trial registration number: 99747069.) RESULTS: Improvements were found on the primary (Liebowitz Social Anxiety Scale) and all five secondary outcome measures in both CBT groups compared with the waiting list. Conducting exposure in VR was more effective at post-treatment than in vivo on the primary outcome measure and on one secondary measure. Improvements were maintained at the 6-month follow-up. VR was significantly more practical for therapists than in vivo exposure. Conclusions: Using VR can be advantageous over standard CBT as a potential solution for treatment avoidance and as an efficient, cost-effective and practical medium of exposure.
Full-text available
This paper provides a review of scientific literature about relaxation training and its effects on anxiety. Research investigating progressive relaxation, meditation, applied relaxation and autogenic training were considered. All these methods proved to be effective in reducing anxiety in all kind of samples, affected or not by physical or psychological disorders. This review supports the efficacy of relaxation training as a valid stand-alone or combined treatment for anxiety disorders or problems and suggests a wider use of these techniques in the clinical practice.
Full-text available
The Center for Advanced Multimedia Psychotherapy at the California School of Professional Psychology in San Diego was established to conduct research and provide clinical treatment to persons with phobias and other mental health disorders by using virtual environments as an adjunct to traditional cognitive-behavioral therapy. Observations made over the course of 600 virtual reality sessions are discussed in this article. Physiological and self-report data collected during treatment support the effectiveness of virtual reality exposure as a useful adjunct in the treatment of phobias. The use of immersive virtual environments appears to augment treatment success through the construct of "presence."
Learning objectives After participating in this activity, learners should be better able to: Abstract Virtual reality (VR) allows users to experience a sense of presence in a computer-generated, three-dimensional environment. Sensory information is delivered through a head-mounted display and specialized interface devices. These devices track head movements so that the movements and images change in a natural way with head motion, allowing for a sense of immersion. VR, which allows for controlled delivery of sensory stimulation via the therapist, is a convenient and cost-effective treatment. This review focuses on the available literature regarding the effectiveness of incorporating VR within the treatment of various psychiatric disorders, with particular attention to exposure-based intervention for anxiety disorders. A systematic literature search was conducted in order to identify studies implementing VR-based treatment for anxiety or other psychiatric disorders. This article reviews the history of the development of VR-based technology and its use within psychiatric treatment, the empirical evidence for VR-based treatment, and the benefits for using VR for psychiatric research and treatment. It also presents recommendations for how to incorporate VR into psychiatric care and discusses future directions for VR-based treatment and clinical research.
Decades of research and more than 20 randomized controlled trials show that Virtual Reality exposure therapy (VRET) is effective in reducing fear and anxiety. Unfortunately, few providers or patients have had access to the costly and technical equipment previously required. Recent technological advances in the form of consumer Virtual Reality (VR) systems (e.g. Oculus Rift and Samsung Gear), however, now make widespread use of VRET in clinical settings and as self-help applications possible. In this literature review, we detail the current state of VR technology and discuss important therapeutic considerations in designing self-help and clinician-led VRETs, such as platform choice, exposure progression design, inhibitory learning strategies, stimuli tailoring, gamification, virtual social learning and more. We illustrate how these therapeutic components can be incorporated and utilized in VRET applications, taking full advantage of the unique capabilities of virtual environments, and showcase some of these features by describing the development of a consumer-ready, gamified self-help VRET application for low-cost commercially available VR hardware. We also raise and discuss challenges in the planning, development, evaluation, and dissemination of VRET applications, including the need for more high-quality research. We conclude by discussing how new technology (e.g. eye-tracking) can be incorporated into future VRETs and how widespread use of VRET self-help applications will enable collection of naturalistic "Big Data" that promises to inform learning theory and behavioral therapy in general.
Conference Paper
This article presents a fully immersive portable low-cost Virtual Reality system to train classroom management skills. An instructor controls the simulation of a virtual classroom populated with 24 semi-autonomous virtual agents via a desktop-based graphical user interface (GUI). The GUI provides behavior control and trainee evaluation widgets alongside a non-immersive view of the class and the trainee. The trainee's interface uses an Head-Mounted Display (HMD) and earphones for output. A depth camera and the HMD's built-in motion sensors are used for tracking the trainee and for avatar animation. An initial evaluation of both interfaces confirms the system's usefulness, specifically its capability to successfully simulate critical aspects of classroom management.
The aim of this paper is to provide a review of controlled studies of the use of Virtual Reality in psychological therapies (VRT). Medline, PsychInfo, Embase and Web of Science were searched. Only studies comparing immersive virtual reality to a control condition were included. The search resulted in 1180 articles published between 2012 and 2015, of these, 24 were controlled studies. The reviewed studies confirm the effectiveness of VRT compared to treatment as usual, and show similar effectiveness when VRT is compared to conventional treatments. Current developments and future research are discussed.
Recent innovations in behavior modification have, for the most part, detoured around the role of cognitive processes in the production and alleviation of symptomatology. Although self-reports of private experiences are not verifiable by other observers, these introspective data provide a wealth of testable hypotheses Repeated correlations of measures of inferred constructs with observable behaviors have yielded consistent findings in the predicted direction.Systematic study of self-reports suggests that an individual's belief systems, expectancies, and assumptions exert a strong influence on his state of well-being, as well as on his directly observable behavior. Applying a cognitive model, the clinician may usefully construe neurotic behavior in terms of the patient's idiosyncratic concepts of himself and of his animate and inanimate environment. The individual's belief systems may be grossly contradictory; i.e., he may simultaneously attach credence to both realistic and unrealistic conceptualizations of the same event or object. This inconsistency in beliefs may explain, for example, why an individual may react with fear to an innocuous situation even though he may concomitantly acknowledge that this fear is unrealistic.Cognitive therapy, based on cognitive theory, is designed to modify the individual's idiosyncratic, maladaptive ideation. The basic cognitive technique consists of delineating the individual's specific misconceptions, distortions, and maladaptive assumptions, and of testing their validity and reasonableness. By loosening the grip of his perseverative, distorted ideation, the patient is enabled to formulate his experiences more realistically. Clinical experience, as well as some experimental studies, indicate that such cognitive restructuring leads to symptom relief.