Virtual Reality Exposure Therapy for Phobias

Summary:

Virtual-Reality-Expositionstherapie bei Phobien

VRET is an effective approach for treating patients with phobias. Under controlled conditions, the fear-inducing stimulus can be presented gradually and repeatedly, thereby inducing habituation. Due to high development costs, VR programs of sufficient quality—and thus with sufficient patient acceptance—have so far been limited to clinics and specialized centers.

In this paper, we demonstrate how advanced VR solutions can be made accessible to all psychologists and psychotherapists, and propose a five-step protocol for use with patients suffering from phobias. We view computer-generated images as a potential gold standard for phobia treatment and 360° videos as a useful complement to VRET for eliciting a relaxation response.  

Introduction:

Phobias and Exposure Therapy Using Virtual Reality

Anxiety disorders are among the most common mental disorders. A meta-analysis of the global prevalence and incidence of anxiety disorders estimates an average 1-year prevalence of 10.6% for all anxiety disorders. Social phobia (4.5%) and specific phobias (3.0%) are the most common forms [Bandelow, 2001; Wancata et al., 2011; Bandelow et al., 2015; Boeldt et al., 2019]. Social phobia is characterized by inappropriate, often chronic anxiety and avoidance of social situations in which the affected individual might be exposed to interpersonal evaluation. Added to this is the fear of performance-related failure, social shame, and humiliation. What specific phobias have in common is an irrational fear of certain situations or objects, which leads to avoidance behavior and, consequently, to attempts to control the specific anxiety. Phobic disorders frequently occur in relation to animals, confined spaces, heights, airplanes, dangerous objects, blood, physical injuries, medical instruments, or medical settings. Neurobiologically, hyperactivity of the central nucleus of the amygdala can be observed. The psychological distress associated with phobias can vary greatly depending on the severity and the triggering situation [Bandelow, 2001; Bandelow et al., 2015].

Exposure therapy as the primary treatment for phobias

In psychological and psychotherapeutic practice, exposure or confrontation therapy—as used in VR-based exposure therapy—takes center stage. This is considered the most effective method for achieving gradual habituation to the anxiety-inducing stimulus, thereby enabling patients to cope with these situations in a normal manner [Shiban, 2018].

Virtual Reality Exposure Therapy: Exposure in Virtual Environments

For several years now, this form of therapy has also been used with the aid of virtual reality as part of the VR Therapy or virtual realities, and is referred to as Virtual Reality Exposure Therapy (VRET). This approach uses computer-generated immersive 3D environments or 360-degree videos in which patients are confronted with anxiety-provoking situations or objects. In some cases, patients can move virtually through these environments and interact with their surroundings. Patients and therapists can control the degree of confrontation. Accompanying interventions such as relaxation exercises or conversations complement VRET [Shiban, 2018; Boeldt et al., 2019].

This paper aims to discuss the existing research on the effectiveness and acceptance of VRET. We propose a VRET protocol based on two training courses, which, to the best of our knowledge, is the first to also address the use of 360° imagery. We provide an overview of the latest developments in VRET, which could enable virtual reality programs to be widely adopted at a low cost.

The Effectiveness of VRET for Anxiety Disorders and Phobias

Exposure therapy has strong supporting evidence from studies in the context of anxiety disorders. It is based on gradual and repeated exposure to the relevant anxiety-provoking stimuli. In practice, however, it is often difficult to implement. With imagery techniques, the therapist can neither know precisely nor control exactly what the patient is visualizing at any given moment. The ability to generate vivid mental images is not equally developed in everyone and also declines with age. In vivo exposure, on the other hand, is often difficult and requires significant effort to arrange, for example, when a fear of heights is to be habituated to actual heights under therapeutic supervision. Furthermore, patient dropout is a concern with these approaches, as this type of intervention is experienced as stressful and unpleasant [Boeldt et al., 2019]

Advantages of VRET over mental imagery and in vivo exposure

VRET can help avoid or at least reduce these barriers and problems. On the one hand, VR can be highly engaging mentally and emotionally, while also providing a controllable, repeatable, and safe environment for therapy. Findings from neuroscience show that VR images strongly engage the primary visual cortex (V1) and visual working memory. Perception and imagination are based on similar neural processes. The use of VR for specific phobias, such as fear of heights or spiders, has already been well-researched in randomized controlled trials [Boeldt et al., 2019].

Research on the effectiveness of VRET

Carl et al. (2019) reviewed a total of 30 studies involving 1,057 participants, 14 of which focused on specific phobias. The effect size for VRET versus a waiting list was very high (g = 0.90), and moderate to high for VRET versus psychological placebo control groups (g = 0.78). A comparison between VRET and in vivo therapies showed no significant difference in effect size. The findings were consistent across all forms of anxiety disorders examined and indicate that VRET is an effective intervention for anxiety disorders [Carl et al., 2019].

Treatment adherence and dropout rates in VRET

In 2018, Benbow and Anderson published a meta-analysis that estimated the likelihood of patient dropouts [Benbow & Anderson, 2019]. An analysis of 46 studies yielded a treatment adherence rate of 84%. The dropout rate of 16% is slightly lower than the dropout rates of 19.6% and 19.7% reported for in vivo interventions and cognitive behavioral therapy for anxiety disorders, respectively [Swift & Greenberg, 2012; Fernandez et al., 2015; Benbow & Anderson, 2019]. The reasons for discontinuing therapy differed between VR and in vivo settings. In VR, these included a lack of immersion, cyber sickness, difficulties with viewing, and discomfort at having to look at the stimulus while simultaneously speaking with the therapist. In in vivo therapy, the main reason was fear of exposure to the actual anxiety-inducing stimulus [Swift & Greenberg, 2012; Fernandez et al., 2015; Benbow & Anderson, 2019].   

The results of these two meta-analyses are consistent with the findings of Fodor et al. (2018) regarding anxiety disorders and depression. The authors included 39 studies and demonstrated a high effect size of g = 0.79, 95% CI 0.57 to 1.07 for anxiety disorders. VR shows high efficacy compared to control groups, but due to marked heterogeneity, no clear effect on the dropout rate was observed [Fodor et al., 2018].

As early as 2012, Opris et al. summarized the findings from VRET studies on anxiety disorders and found that VRET yields far better results than the waiting-list control group, that the results show similar efficacy between behavioral and cognitive-behavioral interventions, that VRET has powerful real-world effects comparable to those of classic evidence-based treatments, VRET exhibits good stability of results over time and thus a lasting effect; there is a dose-response relationship for VRET, meaning that intensive programs lead to faster results; and there is no difference in dropout rates between virtual reality exposure and in vivo exposure [Opris et al., 2012].

5-Step Protocol for Virtual Reality Exposure Therapy

In 2019, we conducted two training courses in Graz and Vienna, among other locations, with clinical psychologists and psychotherapists, during which VR programs were created using 8K footage captured with an Insta 360° Pro camera.

Some participants in the training program treat patients with social anxiety disorder in their practices—patients who rarely venture out among other people. A program was developed for these clients that takes place in a park. It begins with the patient sitting alone on a park bench. Gradually, other people (the participants) join them, thereby increasing the patient’s exposure to social interaction. Using a controller, the patient can stop the gradually increasing challenge at any time.

Exam anxiety and public speaking are also common reasons why participants visit a practice. For this reason, the group simulated a seminar audience and, later on, an exam committee.

All three scenarios—the park bench, the presentation, and the exam—are available to patients via Oculus GO 32GB VR headsets. Graduates can learn to handle these situations confidently and competently in a realistic environment created by the 360° footage. However, this approach does not offer any interactivity.

In addition, supplementary interventions are practiced that can be combined with VR programs. For example, resources such as places of power—activated through a VR application—can be repeatedly located and expanded upon. Alternatively, relaxation scenes, such as soothing natural landscapes, can be used to support a client in the context of VRET.

A particular challenge in using such programs is that some patients cannot tolerate the realistic VR scenarios at first. The great strength of VR lies in its lifelike experience, but this very aspect can initially be a barrier for people experiencing significant distress. If this experience is too overwhelming, it is necessary to start with less intense forms of immersion.

Gradual exposure to anxiety-provoking situations

Step 1: The client maintains a distance from the relevant situations while still gently confronting them. This can be achieved, for example, using images or videos that do not trigger anxiety. With just a few clicks, images and videos on virtually any topic can be found using search engines. A laptop or tablet can be used for this purpose. Alternatively, images can be printed out in advance. Most clients will likely have no problem with this mild form of confrontation.

Step 2: The client still maintains a sense of distance from the relevant situations. But in this step, with their eyes closed, the client uses their imagination to visualize certain places where the anxiety-provoking situations are no longer far away. For example, the building across the street where an exam is taking place or where there is an elevator. Or a soccer field that you’ll soon have to leave, where you have to walk through a narrow tunnel to get to the front. Or a deserted park that you’ll soon be leaving to head toward the city center

Step 3: Now, for the first time, the client attempts to use their imagination to form a milder association with the anxiety-provoking situation. In their mind, they enter the building and step into the elevator. They enter the room and begin their presentation or greet the examination committee. Or, in their imagination, they leave an empty seat and seek out the company of others. 

Step 4: In the penultimate step, the client enters a state of intense associative perception through the VR scenario. Before Step 4 can be undertaken, some clients require several sessions focused on Steps 1–3

Step 5: The client places themselves in a (formerly) anxiety-provoking situation in real life. Depending on the feedback, Step 4 is repeated several times.

Supplementary relaxation strategies in VR exposure

To complement this gradual increase in awareness, a physical relaxation exercise can be helpful for the client as soon as the client reports symptoms of tension or these become apparent even without the client’s feedback. Initial reports from participants regarding their use of this strategy with patients indicate its effectiveness and acceptance. This VRET protocol was tested using 360° videos but can also be used without modification for computer-generated environments.

Discussion

The Potential and Limitations of VR Exposure Therapy for Phobias

The effect size for VRET interventions compared to controls is very high. VR can therefore be classified as a highly effective approach for treating phobias. The dropout rate is low at 16%, though no significant difference was found compared to in vivo therapies. Since “real-life exposure” is associated with significant fear among patients and leads to treatment discontinuation in this context, VRET holds great potential for even higher patient acceptance.

Advantages and Limitations of VR Exposure Therapy

The advantages of VRET are: it is easily accessible, cost-effective, can be performed as often as needed (e.g., the takeoff of an airplane), and the patient has full control over the scene. Lack of immersion, motion sickness, difficulties in viewing the scene, and discomfort caused by having to look at the scene while speaking with the therapist are the most common limitations, which contribute to the inherently low dropout rate. The dropouts indicate that VRET benefits from high-quality VR programs where the aforementioned advantages can actually be leveraged effectively. For the best possible immersion, computer-generated spaces with position tracking are recommended, as they allow for interactive movement. To prevent cyber sickness and discomfort during viewing, the principle of stimulus minimization applies—that is, scenarios designed to be as simple as possible. 

As part of two training courses, psychologists and psychotherapists created VRET scenarios through video recordings, with the level of exposure gradually increasing. The reports from course participants using this protocol indicate that this approach combines satisfactory effectiveness with patient acceptance, albeit with some compromise in immersion. A clinical study on this topic could evaluate this experience more closely and increase the level of evidence, allowing such videos to be used in isolated cases as a cost-effective alternative to computer-generated rooms.

Relaxation and 360-degree natural scenery to round out the experience

It is also recommended to incorporate relaxation exercises into phobia treatment. VR can be used to deliver relaxation programs. Using VR for relaxation could help patients stop associating VR solely with negative stimuli, which could have a positive impact on their acceptance of the technology. Furthermore, VR is a very effective tool for achieving rapid physiological recovery from stressors, as demonstrated by a study at the University of Salzburg measuring heart rate variability and pulse (Täuber M. & Altenhofer M., manuscript in preparation).

We recommend starting with one to three hours of the five-step protocol described above and supplementing it with relaxation strategies. It is important to focus initially on building sufficient trust and rapport. We also recommend using high-quality VRET, allowing patients to immerse themselves in virtual realities step by step.

Update 2023: New Developments in VR Exhibition

Hardware and software have advanced significantly in recent years. In addition to phobias, VR exposure therapy is also used in Addiction und Depression an increasingly important role. You can find more information on this topic on these pages.

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Autoren:
Michael Altenhofer
Dr. Marcus Täuber


Dieser Artikel erschien 2020 im deutschen Magazin „Verhaltenstherapie & Verhaltensmedizin“