Using Virtual Reality Exposure Therapy in

the Treatment of Phobia

Amy Dunn, Gemma Hunt, Caroline Osborn and Phil Sequeira

Phobias

• Phobias are traditionally treated using exposure therapy or systematic desensitisation (Wolpe, 1958)

• Repeated exposure to phobic stimulus + relaxation techniques + components of CBT = gradually minimised phobic anxiety

• Phobias are irrational fears of non-threatening stimuli, involving physiological and cognitive stress

• BUT provision of exposure can present some serious challenges…

Controversies

• VR exposure therapy attempts to overcome these problems

• Safety issues - confronting fear in real situations (Newman and Adams, 2004)

• Ethical considerations/client confidentiality issues resulting from real-world context (Davidson and Smith, 2003)

VR Exposure Therapy

• VRET is not a new therapeutic system, but a tool for use in established methods

•e.g. systematic desensitisation and cognitive-behavioural therapies (CBTs)

• The use of VR in the treatment of phobia can offer increased control and containment of therapy (Klinger et al., 2005)

• Virtual reality exposure therapy (VRET) relates to the use of virtual environments (VEs) as a tool for the graded exposure to a phobic stimulus

Controversies in VRET

• Cyber-sickness– “a kind of motion sickness induced by discrepancies

between visual, vestibular and proprioceptive information” (Robillard et al., 2003:468)

• Transferability of skills• Effectiveness in inducing enough anxiety to

treat phobias (Krijn et al., 2003)

• Cost• Presence and immersion

– The “feeling of being in an environment even if one is not physically present” (Robillard et al., 2003:468)

The Virtual Reality Suite

• This is achieved using three separate projected displays, which are blended together to create one “seamless” image

• The projectors and a rack containing all the image generators are located behind the screen in the projection room

• The VR theatre is designed to display large stereoscopic virtual imagery to a seated audience

Case Study

• Anxiety and Presence during VR Immersion: A Comparative Study of the Reactions of Phobic and Non-phobic Participants in Therapeutic Virtual Environments Derived From Computer Games (TVEDGs)• Robillard, Bouchard, Fournier and Renaud (2003)

Aims and Rationale• TVEDGS

• VEs created using standard computer games, which cost less than $50 and are compatible with PCs

• Can be modified by users with little computing experience

• Graphic quality is often superior• Aims

• Do TVEDGs evoke appropriate phobic reaction?

• To assess the impact of simulator-sickness and sense of presence

Method• Sample

– 13 phobic participants and 13 non-phobic participants, matched for age and gender

– Phobias were arachnophobia, acrophobia and claustrophobia

• Procedure– 5 minutes to familiarise with VE and equipment (HMD,

tracker and game-pad) without phobic stimuli– 20 minute session with phobic stimuli: both phobic

and non-phobic participants experience the same phobic cues and are encouraged to interact with them

– Verbal reports regarding anxiety, immersion and cyber-sickness given throughout and assessed by questionnaire at the end

The Virtual Environments

• Virtual environment for phobia of spiders - Version 2 (developed from Max Payne™)

The Virtual Environments

• Virtual environment for phobia of heights - Version 2 (developed from Max Payne™)

The Virtual Environments

• Virtual environment for claustrophobia - Version 1 (developed from Unreal Tournament™)

Results

• Pre-exposure:• Phobic participants had significantly higher levels

of anxiety and a higher propensity to immerse

• During exposure:• All participants except one reported low anxiety in

neutral VEs

• Post-immersion:• Phobic participants reported greater anxiety and

sense of presence• Phobic participants reported greater simulator

sickness (though not significant)

Discussion• Aim 1 – Can TVEDGs produce phobogenic

stimuli?• Results show that anxiety was the product of

VE stimuli and not VR equipment• Using TVEDGs, for a quarter of the cost of

commercial VRTs, therapists can provide an equivalent level of treatment

• Aim 2 – What is the impact of simulator-sickness?

• Results suggest that simulator-sickness has no impact on phobogenic efficacy

• Adaptation effects – Regan, 1995

Discussion

• Aim 2 – What is the impact of presence?• Anxiety was importantly related to sense of

presence• Group differences show that it was phobic

participants who had a greater tendency to immerse

• Correlations and regressions show that anxiety and presence were the most highly correlated variables and most predictive of each other

• These findings support a synergistic relationship but the underlying reasons remain unclear

Conclusions of the Study

• Secondly, the findings demonstrate that high-costs, issues relating to immersion, and side-effects such as cyber-sickness, need not remain barriers to effectiveness in the use of VEs to treat phobia

• Firstly, phobogenic effectiveness of the inexpensive software used, shows that VR technology is now sufficiently advanced for VRET to move into the clinical mainstream

Remaining Issues

• Retrospective questionnaire• Accuracy of recall

• Transferability of skills• Standardised environments – Individual

differences?• Testing software efficacy/testing

therapeutic efficacy

• Verbal reports• Impact on immersion• Demand characteristics

Thank you for listening

Any Questions?

References• Davidson, J., and Smith, M. (2003). Biophobias/technophilias:

Virtual reality exposure as treatment for phobias of nature. Sociology of Health and Illness, 25(6), 644-661.

• King, N.J., Muris, P., and Ollendick, T.H. (2005). Childhood fears and phobias: Assessment and treatment. Child and Adolescent Mental Health, 10(2), 50-56.

• Klinger, E., Bouchard, S., Legeron, P., Roy, S., Lauer, F., Chemin, I., and Nugues, P. (2005). Virtual reality therapy Vs cognitive behaviour therapy for social phobia: A preliminary controlled study. Cyberpsychology and Behaviour, 8(1), 76-88.

• Krijn, M., Emmelkamp, P.M.G., Biemond, R., de Wilde de Ligny, C., Shuemie, M.J., and van der Mast, C.A.P.G. (2003). Treatment of acrophobia in virtual reality: The role of immersion and presence. Behaviour Research and Therapy, 42, 229-239.

References• Newman, C., and Adams, K. (2004). Dog gone good:

Managing dog phobia in a teenage boy with a learning disability. British Journal of Learning Disabilities, 32, 35-38.

• Regan, E.C. (1995). Some evidence of adaptation to immersion in virtual reality. Displays, 16(3), 135-139.

• Robillard, G., Bouchard, S., Fournier, T., and Renaud, P. (2003). Anxiety and presence during VR immersion: A comparative study of the reactions of phobic and non-phobic participants in therapeutic virtual environments derived from computer games. Cyberpsychology and Behaviour, 6(5), 467-476.

• Virtual environments. Retrieved May 13th 2005, from: http://www.uqo.ca/cyberpsy/index-en.html

References• Davidson, J., and Smith, M. (2003). Biophobias/technophilias:

Virtual reality exposure as treatment for phobias of nature. Sociology of Health and Illness, 25(6), 644-661.

• King, N.J., Muris, P., and Ollendick, T.H. (2005). Childhood fears and phobias: Assessment and treatment. Child and Adolescent Mental Health, 10(2), 50-56.

• Klinger, E., Bouchard, S., Legeron, P., Roy, S., Lauer, F., Chemin, I., and Nugues, P. (2005). Virtual reality therapy Vs cognitive behaviour therapy for social phobia: A preliminary controlled study. Cyberpsychology and Behaviour, 8(1), 76-88.

• Krijn, M., Emmelkamp, P.M.G., Biemond, R., de Wilde de Ligny, C., Shuemie, M.J., and van der Mast, C.A.P.G. (2003). Treatment of acrophobia in virtual reality: The role of immersion and presence. Behaviour Research and Therapy, 42, 229-239.

References• Newman, C., and Adams, K. (2004). Dog gone good:

Managing dog phobia in a teenage boy with a learning disability. British Journal of Learning Disabilities, 32, 35-38.

• Regan, E.C. (1995). Some evidence of adaptation to immersion in virtual reality. Displays, 16(3), 135-139.

• Robillard, G., Bouchard, S., Fournier, T., and Renaud, P. (2003). Anxiety and presence during VR immersion: A comparative study of the reactions of phobic and non-phobic participants in therapeutic virtual environments derived from computer games. Cyberpsychology and Behaviour, 6(5), 467-476.

• Virtual environments. Retrieved May 13th 2005, from: http://www.uqo.ca/cyberpsy/index-en.html

References• Davidson, J., and Smith, M. (2003). Biophobias/technophilias:

Virtual reality exposure as treatment for phobias of nature. Sociology of Health and Illness, 25(6), 644-661.

• King, N.J., Muris, P., and Ollendick, T.H. (2005). Childhood fears and phobias: Assessment and treatment. Child and Adolescent Mental Health, 10(2), 50-56.

• Klinger, E., Bouchard, S., Legeron, P., Roy, S., Lauer, F., Chemin, I., and Nugues, P. (2005). Virtual reality therapy Vs cognitive behaviour therapy for social phobia: A preliminary controlled study. Cyberpsychology and Behaviour, 8(1), 76-88.

• Krijn, M., Emmelkamp, P.M.G., Biemond, R., de Wilde de Ligny, C., Shuemie, M.J., and van der Mast, C.A.P.G. (2003). Treatment of acrophobia in virtual reality: The role of immersion and presence. Behaviour Research and Therapy, 42, 229-239.

References• Newman, C., and Adams, K. (2004). Dog gone good:

Managing dog phobia in a teenage boy with a learning disability. British Journal of Learning Disabilities, 32, 35-38.

• Regan, E.C. (1995). Some evidence of adaptation to immersion in virtual reality. Displays, 16(3), 135-139.

• Robillard, G., Bouchard, S., Fournier, T., and Renaud, P. (2003). Anxiety and presence during VR immersion: A comparative study of the reactions of phobic and non-phobic participants in therapeutic virtual environments derived from computer games. Cyberpsychology and Behaviour, 6(5), 467-476.

• Virtual environments. Retrieved May 13th 2005, from: http://www.uqo.ca/cyberpsy/index-en.html

References• Davidson, J., and Smith, M. (2003). Biophobias/technophilias:

Virtual reality exposure as treatment for phobias of nature. Sociology of Health and Illness, 25(6), 644-661.

• King, N.J., Muris, P., and Ollendick, T.H. (2005). Childhood fears and phobias: Assessment and treatment. Child and Adolescent Mental Health, 10(2), 50-56.

• Klinger, E., Bouchard, S., Legeron, P., Roy, S., Lauer, F., Chemin, I., and Nugues, P. (2005). Virtual reality therapy Vs cognitive behaviour therapy for social phobia: A preliminary controlled study. Cyberpsychology and Behaviour, 8(1), 76-88.

• Krijn, M., Emmelkamp, P.M.G., Biemond, R., de Wilde de Ligny, C., Shuemie, M.J., and van der Mast, C.A.P.G. (2003). Treatment of acrophobia in virtual reality: The role of immersion and presence. Behaviour Research and Therapy, 42, 229-239.

References• Newman, C., and Adams, K. (2004). Dog gone good:

Managing dog phobia in a teenage boy with a learning disability. British Journal of Learning Disabilities, 32, 35-38.

• Regan, E.C. (1995). Some evidence of adaptation to immersion in virtual reality. Displays, 16(3), 135-139.

• Robillard, G., Bouchard, S., Fournier, T., and Renaud, P. (2003). Anxiety and presence during VR immersion: A comparative study of the reactions of phobic and non-phobic participants in therapeutic virtual environments derived from computer games. Cyberpsychology and Behaviour, 6(5), 467-476.

• Virtual environments. Retrieved May 13th 2005, from: http://www.uqo.ca/cyberpsy/index-en.html

References• Davidson, J., and Smith, M. (2003). Biophobias/technophilias:

Virtual reality exposure as treatment for phobias of nature. Sociology of Health and Illness, 25(6), 644-661.

• King, N.J., Muris, P., and Ollendick, T.H. (2005). Childhood fears and phobias: Assessment and treatment. Child and Adolescent Mental Health, 10(2), 50-56.

• Klinger, E., Bouchard, S., Legeron, P., Roy, S., Lauer, F., Chemin, I., and Nugues, P. (2005). Virtual reality therapy Vs cognitive behaviour therapy for social phobia: A preliminary controlled study. Cyberpsychology and Behaviour, 8(1), 76-88.

• Krijn, M., Emmelkamp, P.M.G., Biemond, R., de Wilde de Ligny, C., Shuemie, M.J., and van der Mast, C.A.P.G. (2003). Treatment of acrophobia in virtual reality: The role of immersion and presence. Behaviour Research and Therapy, 42, 229-239.

References• Newman, C., and Adams, K. (2004). Dog gone good:

Managing dog phobia in a teenage boy with a learning disability. British Journal of Learning Disabilities, 32, 35-38.

• Regan, E.C. (1995). Some evidence of adaptation to immersion in virtual reality. Displays, 16(3), 135-139.

• Robillard, G., Bouchard, S., Fournier, T., and Renaud, P. (2003). Anxiety and presence during VR immersion: A comparative study of the reactions of phobic and non-phobic participants in therapeutic virtual environments derived from computer games. Cyberpsychology and Behaviour, 6(5), 467-476.

• Virtual environments. Retrieved May 13th 2005, from: http://www.uqo.ca/cyberpsy/index-en.html

References• Davidson, J., and Smith, M. (2003). Biophobias/technophilias:

Virtual reality exposure as treatment for phobias of nature. Sociology of Health and Illness, 25(6), 644-661.

• King, N.J., Muris, P., and Ollendick, T.H. (2005). Childhood fears and phobias: Assessment and treatment. Child and Adolescent Mental Health, 10(2), 50-56.

• Klinger, E., Bouchard, S., Legeron, P., Roy, S., Lauer, F., Chemin, I., and Nugues, P. (2005). Virtual reality therapy Vs cognitive behaviour therapy for social phobia: A preliminary controlled study. Cyberpsychology and Behaviour, 8(1), 76-88.

• Krijn, M., Emmelkamp, P.M.G., Biemond, R., de Wilde de Ligny, C., Shuemie, M.J., and van der Mast, C.A.P.G. (2003). Treatment of acrophobia in virtual reality: The role of immersion and presence. Behaviour Research and Therapy, 42, 229-239.

References• Newman, C., and Adams, K. (2004). Dog gone good:

Managing dog phobia in a teenage boy with a learning disability. British Journal of Learning Disabilities, 32, 35-38.

• Regan, E.C. (1995). Some evidence of adaptation to immersion in virtual reality. Displays, 16(3), 135-139.

• Robillard, G., Bouchard, S., Fournier, T., and Renaud, P. (2003). Anxiety and presence during VR immersion: A comparative study of the reactions of phobic and non-phobic participants in therapeutic virtual environments derived from computer games. Cyberpsychology and Behaviour, 6(5), 467-476.

• Virtual environments. Retrieved May 13th 2005, from: http://www.uqo.ca/cyberpsy/index-en.html