Virtual-reality-assisted treatment of flight phobia
Flight phobia is a common and debilitating specific phobia. Recently, an effective technology, called Virtual Reality (VR), has been developed for the treatment of various anxiety disorders including flight phobia. This article reports the results of a pilot study consisting of four subjects treated for Flight Phobia using Virtual Reality. All four subjects flew post-treatment. They experienced a significant reduction in fear of flying on two measures--anxiety about flying and global rating of fear of flying. Limitations: due to the small sample size, the lack of a control group, and the lack of objective measures, caution must be exercised in interpreting the results. The use of Virtual Reality psychotherapy is relatively new worldwide, as well as in Israel. This study suggests the utility of implementing this technology in Israel.
Virtual-Reality-Assisted Treatment of Flight Phobia
Helene S. Wallach, PhD,1,2 and Margalit Bar-Zvi, MD3
1Tsfat College, Tsfat, Israel
2Department of Behavioral Studies, Emek Yezreel College, Emek Yezreel, Israel
3Psychiatric Outpatient Clinic, Ziv Hospital Tsfat, Israel.
Abstract: Background: Flight phobia is a common and debilitating specific phobia. Recently, an effective technology,
called Virtual Reality (VR), has been developed for the treatment of various anxiety disorders including flight phobia.
Method: This article reports the results of a pilot study consisting of four subjects treated for Flight Phobia using Vir-
tual Reality. Results: All four subjects flew post-treatment. They experienced a significant reduction in fear of flying on
two measures — anxiety about flying and global rating of fear of flying. Limitations: Due to the small sample size, the
lack of a control group, and the lack of objective measures, caution must be exercised in interpreting the results. Con-
clusions: The use of Virtual Reality psychotherapy is relatively new worldwide, as well as in Israel. This study suggests
the utility of implementing this technology in Israel.
This paper will focus on a specific phobia — fear of
flying (1). Approximately 10%-25% of the popula-
tion suffer from this specific phobia. The discomfort
created by the phobia ranges from a mild annoyance
to a major disturbance. In addition, approximately
20% of those who fly depend on sedatives or alcohol
during flights (2, 3).
The combination of cognitive and behavior ther-
apy (CBT) has been found to be the treatment of
choice for phobias (4). This combination is superior
to all other psychotherapeutic approaches, in the
ment as well as long-term effects in follow-up
Virtual reality (VR) is defined as a situation in which
the information arriving through the senses is fed
from a computer. The more senses involved, and the
higher the degree of accuracy in the presentation, the
higher the sense of immersion, and thus it becomes
harder for the client to discriminate between the
“real” and the “virtual” reality. The use of VR in ther-
apy is relatively new. Its advantage is opening up an
alternative to in-vivo exposure and increasing gener-
In VR therapy for flight phobia, the client re-
ceives visual, audio and tactile (vibrations) input
from the program. The therapist monitors the cli-
environment level, if needed.
Advantage Using VR Therapy
Research has repeatedly found that exposure in-vivo
is superior to exposure in imagination, although it is
ments. For example, for flight phobia we need to rent
an airplane and perform multiple takeoffs and land-
ings. This entails traveling to an airport which in
most cases is far from the clinic, thus increasing time
and cost, the high costs in renting a plane and paying
a pilot. An additional problem with in-vivo exposure
is encountering people the client knows and thus ex-
posing the fact s/he is in therapy.
The advantages of VR therapy over imaginal
therapy are for people who have difficulty imagining
situations vividly, or for those who avoid staying in
the imagined fearful situation. In addition, with VR
the therapist has full knowledge of and control over
Research Using VR for Flight Phobia
VR therapy has been used for specific phobias (6).
Isr J Psychiatry Relat Sci Vol 44 No. 1 (2007) 29–32
Address for Correspondence: Dr. Helene S. Wallach, Department of Behavioral Studies, Emek Yezreel College, Emek
Yezreel 19300, Israel. E-mail: helenwa@Yahoo.com, email@example.com
Four controlled studies combining VR and CBT
have found VR an effective tool for flight phobia (2,
7–11). However, in one study the post-treatment ef-
fect was lost by follow-up (7), in another only two-
thirds of the patients actually flew by follow-up (8),
and in the third no differences were found between
the treatment and waitlist group on actual flying
rates (9). Only one study found significant differ-
ences both post-treatment and in follow-up (2, 10,
The present study proposed to examine the utility
of virtual reality psychotherapy for flight phobia in
an Israeli population. The hypothesis was that VR
psychotherapy will reduce fear of flight ratings.
Four subjects (three women and one man), who met
DSM-IV-TR criteria for specific phobia flight partic-
ipated in this study.
1. Flight anxiety situations questionnaire (FAS).
This questionnaire includes 31 questions relating
various flight situations and asks the subject to
rate the level of anxiety he/she feels in each, on a
five-point Likert scale ranging from 1 (no anxi-
ety) to 5 (overwhelming anxiety).
2. Flight anxiety modality questionnaire (FAM).
This questionnaire includes 23 questions relating
to expression of fear during flying. Each question
is rated on a five-point Likert scale ranging from
Both questionnaires (12) are used by the Valk
Institute and were translated into Hebrew by
Galit Rosenberg. Both have high reliability in
their original language and after translation to
3. Questionnaire on attitudes toward flying (QAF)
(12). This questionnaire assesses history of fear of
flying, previous treatment and attitudes towards
flying. It contains 36 questions rating the level of
fear in different flying situations on a Likert scale
ranging from 0–11. Test retest reliability was .92
and split half reliability was .99.
4. After treatment, subjects flew accompanied by a
research assistant on a short flight (30 minutes),
waited at the airport for a couple of hours and
flew back. They rated their anxiety using SUDS
(0–100) at various points from entrance to the
terminal until leaving the plane at the end of the
Subjects were recruited through advertisements in
local newspapers. They were interviewed by a psy-
chiatrist (the second author). Exclusion criteria
were: psychotic disorders, psychoactive substance
abuse and seizures. Only those who suffered from
flight phobia were included. All subjects filled out
the questionnaires. Following treatment they flew
with the research assistant on a short (30 minutes)
domestic flight, waited at the terminal for several
hours and flew back. They received eight sessions
of treatment administered according to a protocol
Treatment: Subjects were taught relaxation, built an
anxiety hierarchy, and performed virtual reality ex-
posure for eight sessions lasting 45 minutes each ses-
sion. Patients started in a stationary airplane and
progressed through the stages only when their SUDS
level was below 30.
The three fear of flight measures taken before treat-
ment were compared to those taken after treatment
(see Table 1). The difference in the flight anxiety mo-
dality questionnaire (FAM) was not significant
(t=1.30, p=0.14). Therefore, VR therapy did not
help patients reduce their expression of fear during
Two questionnaires were used for the level of fear
during flying situations. On one no significant dif-
ference was found, yet on the other there was a sig-
nificant difference. The difference for the
questionnaire on attitudes toward flying (QAF) was
not significant (t=1.45, p=0.14). The difference
for the flight anxiety situations questionnaire (FAS)
was significant (t=3.59, p=0.02).
Comparing the SUD level on the two post-treat-
ment flights approached significance (t=2.10,
30 VIRTUAL-REALITY TREATMENT OF FLIGHT PHOBIA
Table 1. Scores on Fear of Flight Measures (Pre- and Post-Scores)
Time FAM FAS QAF SUDa
N M SD N M SD N M SD N M SD
Pre 4 62.00 15.34 4 112.75* 6.02 3 226.67 60.14 4 26.70 13.63
Post 4 48.25 9.50 4 85.75* 10.63 3 173.67 63.09 4 20.34 17.03
aSUD pre = first flight after treatment, from Rosh Pina to Tel Aviv; post = second flight after treatment, from Tel Aviv to Rosh Pina.
Lastly, rated global fear towards flying, pre-treat-
ment, was compared to average SUD level in post-
treatment flight (see Table 2). This yielded a signifi-
cant difference (t=3.75, p=0.03).
Table 2. Comparing Level of Felt Fear Prior to Treatment
to Average SUD Level on Post-Flight
Measure N M SD
Felt fear prior to treatment 3 70.00* 10.00
Average SUD level during post-
treatment flight 3 15.55* 17.24
The present study was conducted to assess VR treat-
ment for flight phobia on an Israeli population. All
measures were reduced from pre- to post-treatment.
significantly from pre- to post-treatment, while the
difference in the other was not significant. An addi-
tional measure of expression of fear during flying
was reduced, but again not significantly. The com-
parison of a global rating of fear of flying to the aver-
age SUD level rated during an actual flight post-
treatment was also significant. Lastly, this study
compared two post-treatment flights, performed
one after the other with a short delay of 2–3 hours be-
tween them, and found a close to significant result.
Therefore, the fear of flight continues to be reduced
with continued exposure made possible by VR treat-
The major limitations of this study are its small
sample size, the lack of a control group and objective
measures and the lack of a follow-up. It is important
to perform this study again with a large number of
subjects, randomly assigned to treatment and con-
trol groups, to perform blind SUDs ratings on
flights, as well as follow-up.
It is also important to compare VR therapy to
CBT, as well as comparing VR therapy alone to VR
with cognitive elements, to discover whether cogni-
tive elements are necessary for the success of VR ex-
posure therapy for flight phobics.
short (eight session) therapy in virtual reality for fear
tient to benefit from an effective therapy at a lower
nymity and lack of control over external forces.
The authors wish to thank Daniela Shriki, Tsachi
Minerbo, Rachael Markovitz and Arik Cohen who
assisted in running the research.
This research project was made possible by the
aid of a generous research grant, 4731, by the Chief
Scientist of the Israeli Ministry of Health.
1. American Psychiatric Association. Diagnostic and Sta-
tistical Manual of Mental Disorders (4th ed.)(Text rev.).
Washington, DC: Author, 2000.
2. Rothbaum BO, Hodges L, Smith S, Lee J-H, Price L. A
controlled study of virtual reality exposure therapy for
the fear of flying. J Consult Clin Psychol 2000;68:1020–
3. Wiederhold B. Fear of flying, center for advanced mul-
timedia psychotherapy — virtual reality therapies,
4. Marks IM. Living with fear. London: Bitan, 1990.
5. Stever J. Defining virtual reality: Dimensions deter-
mining telepresence, J Communications 1992;42:73–
HELENE S. WALLACH AND MARGALIT BAR-ZVI 31
6. Wiederhold BK, Wiederhold MD. Virtual reality ther-
apy for anxiety disorders: Advances in evaluation and
treatment. Washington, DC: American Psychological
7. Maltby N, Kirsch I, Mayers M, Allen GJ. Virtual reality
controlled investigation. J Consult Clin Psychol 2002;
8. Muhlberger A, Herrmann MJ, Wiedemann G, Ellgring
H, Pauli P. Repeated exposure of flight phobics to
flights in virtual reality. Behav Res Ther 2001;39:1033–
9. Muhlberger A, Wiedemann G, Pauli P. Efficacy of a
one-session virtual reality exposure treatment for fear
of flying. Psychotherapy Res 2003;13:323–336.
10. Rothbaum BO, Hodges L, Anderson PL, Price L, Smith
S. Twelve-month follow-up of virtual reality and stan-
dard exposure therapies for the fear of flying. J Consult
Clin Psychol 2002;70:428–432.
11. Rothbaum BO, Anderson P, Zimand E, Hodges L, Lang
D, Wilson J. Virtual reality exposure therapy and stan-
dard (in vivo) exposure therapy in the treatment of fear
of flying. Behav Ther 2006;37:80–90.
12. Van Gerwen LJ, Spinhoven P, VanDyck R, Diekstra
RFW. Construction and psychometric characteristics
of two self-report questionnaires for the assessment of
fear of flying. Psychological Assessment 1999;11:146–158.
13. Rothbaum BO, Hodges L. Therapist treatment manual
for virtual reality exposure therapy of fear of flying.
Unpublished manuscript. 1997.
32 VIRTUAL-REALITY TREATMENT OF FLIGHT PHOBIA
Ministry of Justice
The Public Defender Office
Invitation for Offers to be included in Pool of Expert
Psychiatrists, Psychologists and Clinical Criminologists
The Public Defender Office requests offers from physicians specializing in psychiatry who
are duly licensed to practice in Israel, and from psychologists and clinical criminologists,
who are interested in being appointed on its behalf to provide advice and expert opinions
in criminal proceedings.
The Public Defender Office will order services, from time to time and as necessary, from
psychiatrists, psychologists or clinical criminologists in the pool. Compensation for the
work performed will be paid in accordance with the provisions of section 7 of the Public
Defender Regulations, — 1996, or in accordance with a special contract that will be signed.
Interested persons are requested to respond in writing no later than 30/5/07 attaching
their resumé and certificates, to the National Office of the Public Defender,
4 Henriette Szold Street, PO Box 33246, Tel Aviv, Fax 03-6932616.