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Editorial
The Future of Virtual Reality Therapy for Phobias:
Beyond Simple Exposures
Alexander Miloffa, Philip Lindnerab , Per Carlbringa
[a] Department of Psychology, Stockholm University, Stockholm, Sweden. [b] Centre for Psychiatry Research, Department
of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Stockholm County, Stockholm, Sweden.
Clinical Psychology in Europe, 2020, Vol. 2(2), Article e2913, https://doi.org/10.32872/cpe.v2i2.2913
Published (VoR): 2020-06-30
Corresponding Author: Per Carlbring, Department of Psychology, Stockholm University, 106 91 Stockholm,
Sweden. E-mail: per@carlbring.se
Inelegant as they may look to the outsider, the white boxy Samsung Gear VR goggles
with a smartphone strapped to the front, have the power to change lives. In the last few
years our research team at Stockholm University have used the device to treat nearly
100 spider phobic patients with virtual reality exposure therapy (VRET) using the Itsy
application, developed alongside VR-startup Mimerse (Miloff et al., 2016). The real tears
patients shed may be indication enough that the animated spiders and computer-gener‐
ated world are helping them face their deepest fears. However, evidence shows large
reductions in self-reported fear and avoidance around live spiders. In fact, the positive
behavior change is very nearly as powerful as the gold-standard treatment for spider
phobia that ends with handling a 3-centimeter spider with their hands (Miloff et al.,
2019). The boundary for how we perceive real and artificial may not be as large as we
think.
Today, the biggest tech companies are still pouring enormous resources into making
virtual a reality. Facebook purchased Oculus, shipped the Rift, the mobile Go and now
Quest, Google had the Daydream-standard and is now moving onto augmented-reality,
Sony the Playstation VR and even Apple is said to be working on a device. Still, there is
a feeling in this industry that it isn’t really clear what virtual reality is good for. There
are entertaining games available sure, mostly shooters and rhythm games. There is the
extremely enjoyable feeling of awe to be dropped into a virtual world somewhere, flying
in a fighter jet or swimming with divers. New ways of storytelling are certainly possible
and are being created. However, there is the persistent feeling that something is missing.
The technology is just too powerful for the limited experiences we’ve developed so far.
This is an open access article distributed under the terms of the Creative Commons Attribution
4.0 International License, CC BY 4.0, which permits unrestricted use, distribution, and
reproduction, provided the original work is properly cited.
To understand what is possible, it may be best to look at the way our reality
generating system functions and work backwards. Our eyes, ears, taste and touch are
geared towards favoring certain information over others (Bayle et al., 2009; Erlich et al.,
2013; Öhman & Mineka, 2001). Sudden movement in the corner of our eye evokes a
fear response, as does the sound of a potentially violent individual above the din of a
crowd, or the unexpected irritation of a wriggling bug on our skin. See a certain shape
walk by and lust towards an attractive mate might cause butterflies in the stomach. The
most common use of virtual reality in clinical treatments is for phobias and similar to
face-to-face treatment is almost always seen through the lens of stimulus-emotion pairs
and exposure therapy (Turner & Casey, 2014). With virtual reality, however, we might
be able to explore not only working to modify basic emotions using simple stimuli but
higher order functions of the mind using complex simulations as well.
For millions of years we sat on the savannah around open fires. The rustling and
movement in tall grasses at the far edge of the camp may be just the wind but our minds
see a leaping lion ready to disembowel us. Gifted with large brains capable of complex
pattern recognition and learning, we’ve developed immense capabilities of prediction.
For want of a better word, this is the power of imagination and at its most vivid. We see
in our mind’s eye a disaster before we experience it. We feel ourselves drowning before
we ever get on the boat. We feel the wind on our face and the sensation of hitting the
ground before we ever step onto the airplane. In the right frame of mind, we may have
even pictured the previous two sentences in our imagination as we read them. Although
this capacity is one of the ways we define ourselves as human, it’s also responsible for
great suffering, catastrophic fears, debilitating anxiety; its moderation actually one of
the ways we define treatment success in specific phobia, i.e., no longer believing your
catastrophic fears (Davis et al., 2012).
We are just at the beginning of exploring the many uses of VR and its practical
application to clinical psychology. Tremendous progress has been made at importing
what we know from traditional formats for psychological treatments (e.g., exposure ther‐
apy), but new and more innovative leaps in understanding and technique are possible.
The capacity of imagination is something we take for granted and generalized solutions
for dealing with its problematic aspects limited. Virtual reality offers a nearly limitless
world in which to create, restricted only by development costs and again, the more
useful aspects of our imagination. The industry driving development of the technology
is searching for the killer app that could convince new users to jump in, and clinical
applications that converge with the gaming industry and storytelling might offer such
an opportunity. Whether such generalized solutions are possible is uncertain, however
what is certain is that the future of clinical treatment and virtual reality is more than just
simple exposures.
Editorial 2
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2020, Vol.2(2), Article e2913
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Funding: The authors have no funding to report.
Competing Interests: Author PL has consulted for Mimerse but holds no financial stake in the company. No
potential conflict of interest was reported by AM or PC.
Acknowledgments: The authors have no support to report.
References
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https://doi.org/10.1371/journal.pone.0008207
Davis, T. E., Ollendick, T. H., & Öst, L.-G. (Eds.). (2012). Intensive one-session treatment of specific
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Erlich, N., Lipp, O. V., & Slaughter, V. (2013). Of hissing snakes and angry voices: Human infants
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Miloff, A., Lindner, P., Dafgård, P., Deak, S., Garke, M., Hamilton, W., . . . Carlbring, P. (2019).
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Öhman, A., & Mineka, S. (2001). Fears, phobias, and preparedness: Toward an evolved module of
fear and fear learning. Psychological Review, 108(3), 483-522.
https://doi.org/10.1037/0033-295X.108.3.483
Turner, W. A., & Casey, L. M. (2014). Outcomes associated with virtual reality in psychological
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Clinical Psychology in Europe
2020, Vol.2(2), Article e2913
https://doi.org/10.32872/cpe.v2i2.2913
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