Virtual Reality Exposure Therapy in the Treatment of Fear of Flying

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Journal of Contemporary Psychotherapy [jcp] PH003-290595 December 23, 2000 14:13 Style file version Nov. 19th, 1999

Journal of Contemporary Psychotherapy, Vol. 30, No. 2, 2000

Virtual Reality Exposure Therapy in the Treatmentof Fear of Flying

Richard A. Klein, Ph.D.

A new and innovative approach to treating fear of flying has been developedusing Virtual Reality Exposure Therapy. This article discusses the developmentof Virtual Reality Exposure Therapy and reviews a case study of a fear of flyingpatient seen in our practice. Early results are very promising and may indicatethat Virtual Reality Exposure Therapy may also lead to creative interventions withother anxiety disorders.

KEY WORDS: Virtual reality therapy; fear of flying; anxiety disorders.

Fear of flying (FOF) is a disorder that is fairly common and impacts10–20%of the US population (25 million individuals are likely to suffer from fear of flying)(Agras, 1969). This may result in the inability to fly or varied degrees of anxietyor stress for those who do fly. Of those who do fly, it has been estimated that 20%of airline passengers depend on alcohol or sedatives to deal with the anxiety andother symptoms that occur as a result of fear of flying (Agras,1969). Fear of flyingis a serious problem with significant repercussions to individuals and also has animpact on the economy, in general (Roberts, 1989).

The frequency of diagnostic factors underlying fear of flying is roughly bi-modal in distribution. About one-half of the patients who experience a fear offlying symptoms meet the criteria of specific phobias—they are fearful of some-thing happening to the aircraft, e.g., crashing. The other half of the fear of flyingpopulation are agoraphobics, with or without panic disorder—they are fearful ofbeing trapped and having a panic attack (McNally and Loura,1992). Individualswho experience fear of flying may experience a wide range of both physiologi-cal and psychological symptoms. These symptoms may occur during the actualflight or even weeks or months prior to the flight in anticipation of flying. Physicalsymptoms may include rapid heart-beat, tightness or pain in the chest, butterfliesin the stomach, nausea or vomiting, or cold weak, or trembling hands or feet.

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Psychological symptoms may include difficulty in concentrating, worry, dread orfear that something terrible is going to happen, or the feeling of being trapped orpowerless.

Virtual Reality exposure therapy is a new treatment modality that placesthe individual in a “virtual” world, generated by a specialized computer system.The computer system consists of specialized hardware and software to place theindividual in a “virtual world.” Using real-time computer animation, audio input,body tracking technology, immersive visual display, and other perceptual stimuli,the individual enters into a “virtual world.” This interaction between the individualand the virtual world results in a sense of “presence,” i.e., becoming part of thevirtual environment.

In our Virtual Reality fear of flying treatment program (Klein, 1998), basedon the program developed by Drs. Rothbaum and Hodges), the patient wears ahead-mounted display (HMD). The HMD incorporates a number of different as-pects of the Virtual Reality system: 1) A color TV monitor is built into the HMDto reproduce the computer-generated images so that the images fill the patient’scomplete field of view. 2) The orientation of the patient, in three dimensions, iscomputed by the computer based on a tracking device located in the HMD. Thehead position and orientation is communicated to the computer and triangulatesthe patient’s position in space and time. Based on these signals the computercalculates and creates discrete views of the environment drawn on the video dis-play in real time (approximately 20 to 60 times per second). 3) In addition tothe visual queues the patient receives, stereo speakers are also located within theHMD, and allow synchronized auditory queues to be added to the visual environ-ment.

The interaction between the individual and the computer and the creationof the images corresponding to the head and body orientation “places” theindividual within the virtual world and allows the individual to visually ex-plore it from any point of view. This differentiates virtual reality from a com-puter simulation. In a computer simulation the individual does not actively in-teract with the computer; the computer does not modify the image that theindividual experiences, regardless of whether the person is wearing a HMD.The image or experience is not changed by the change in head or bodyorientation.

In addition to the visual and auditory stimuli that immerses the patient intothe virtual aircraft, the computer system has a powerful subwoofer speaker builtinto the patient’s chair. Adding to the visual and auditory stimuli the subwooferincreases the dimensionality and sense of reality by adding vibration to variousaspects of the fear of flying scenarios. For example, when the airplane’s flaps orlanding gear are activated, or when the aircraft enters into the thunderstorm portionof the treatment, intense vibrations are transmitted through the chair to increasethe reality and sense of presence.

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Virtual Reality Exposure Therapy in the Treatment of Fear of Flying 197

RESEARCH STUDIES IN THE TREATMENT OF FEAR OF FLYING

Fear of flying disorders have been treated by a number of therapeutic tech-niques including traditional psychotherapy, systematic desensitization, cognitivepreparation, coping self-talk, stress inoculation training, flooding, implosion, invivo exposure, and relaxation training (Rothbaum, 1997). Physicians who havepatients that experience fear of flying may prescribe one of the minor tranquilizers(e.g., Valium, Xanax, Ativan) or a beta-blocker (e.g., Inderal), in an attempt todeal with anxiety and physiological symptoms, e.g. heart palpitations, shortnessof breath, or diaphoresis that arise with fear of flying.

Fear of flying has typically been treated with behavioral therapies. In review-ing the efficacy of the different therapeutic approaches and the significant impactfear of flying has on the general population, there have been only a limited numberof studies conducted.

Beckham,et al. (1990) evaluated stress inoculation training incorporatingminimal relaxation training (MRT) and cognitive coping strategies, involving min-imal therapist involvement in the treatment of fear of flying. In the study subjectswere given written instruction in stress inoculation training, relaxation training,and cognitive coping strategies. All subjects experienced a post-treatment flight.The subjects assigned to the experimental group were treated for their fear offlying through a written instruction and weekly telephone contact. The Question-naire on Attitudes Toward Flying (QAF) (Howard, 1983) was administered tosubjects pre- and post-test, and eight weeks post-flight. Physiological measure-ments (heart rate) and psychological measurements (SUDs—Subjective Units ofDiscomfort) were collected during the actual flight for all subjects. Results re-flect significant improvement between the experimental and control groups. Theexperimental group had lower QAF scores. In addition, a greater number of the ex-perimental subjects attended the post-treatment session and actual flight. Subjectswho flew as part of the posttreatment assessment revealed more evidence of emo-tional processing during exposure than those individuals who continued to avoidflying. They also had higher heart rates during exposure, greater decrease in heartrate from beginning to end of the flight, and higher differential between pre- andposttreatment self-reports of fear reduction. The results reflect the effectiveness ofminimal anxiety reduction combined with exposure. The results point to the impor-tance of emotional processing components of fear activation and extinction duringexposure.

Howard (1983) examined systematic desensitization, flooding, implosivetherapy, and relaxation training, as compared to a no treatment control groupin the treatment of fear of flying. His results indicate that all treatment modalitieswere equally superior to no treatment. He also found no significant differencesamong the four treatment groups reflecting that none of the treatment modalitieswere statically more effective in treating fear of flying.

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Denholtz and Mann (1975) studied the use of modified systematic desensi-tization modality in the treatment of fear of flying. Their treatment design usednonprofessionals to administer systematic desensitization treatment to fear of fly-ing subjects through an automated audiovisual exposure. Exposure to audiovisualmedia was successful in reducing the level of fear of flying in the test subjects asmeasured by the number of subjects who were able to actually fly posttreatment.The results of the study, however, were limited by the fact that 30 of the subjectsdropped out of treatment.

Haug (1987) evaluated stress inoculation training and applied relaxation train-ing for fear of flying as measured by an actual flight. The data indicated that bothstress inoculation and applied relaxation training were equally effective in reducingsubjects’ physiological arousal and subjective anxiety.

Rothbaum (1996) evaluated the treatment of fear of flying using Virtual Real-ity exposure therapy. The study combined anxiety management techniques (AMT)and Virtual Reality exposure therapy to treat a 42-year old, woman who experi-enced fear of flying. The woman was taught relaxation techniques and thought-stopping training, and was then involved in six sessions of graded exposure toflying in a computer generated virtual reality aircraft. The results of this case studyreflect a reduction in self-report measures of fear and avoidance following the AMTand still greater reductions in these measures following Virtual Reality exposure.The subject completed a posttreatment flight, with anxiety measures reflecting acomfortable flight.

Another early study of fear of flying treatment (North, 1996) used VirtualReality exposure in a virtual helicopter over five sessions. Although the subject’sSUDs decreased over the course of treatment, long-term follow-up data is stillpending.

VIRTUAL REALITY EXPOSURE THERAPY

The first reported study of VR involvement in psychological treatment was anuncontrolled study from Japan. Kijima (1993) used virtual reality to simulate sandplay projective techniques with autistic children. The authors contended that thevirtual reality sand play was “useful” although no data was presented to supporttheir conclusions.

Strickland (1996) reported on preliminary work with autistic children usingvirtual reality as a learning aid. In the study 2 autistic children were exposed toa virtual world and allowed to interact with various elements in that computer-generated virtual world. The author reported that the children were able to identifyfamiliar objects and quantities of those objects, and was also able to locate andmove specific objects in this virtual environment.

Virtual reality in a mixed-media treatment of fear of spiders was studied byCarlin (1997), at the University of Washington Medical Center. The study focused

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on one patient, a woman, who had a 20-year history of severe spider phobia. Thesubject was placed in a virtual environment, “KitchenWorld,” where she expe-rienced interacting with spiders over 12 one-hour treatment sessions. Over thecourse of the treatment sessions the subject was able to interact with spiders visu-ally, hold a virtual and tactile spider (stuffed spider) and squash a VR spider witha mixed reality ping pong paddle. The data yielded significant differences in pre-posttreatment questionnaires regarding fear of spiders for the treatment subject ascompared to the control group. Twenty-nine percent of the students (control group)had higher fear of spiders scores posttreatment as compared to the test subject.

The first controlled study of the use of virtual reality in the treatment of apsychological disorder was conducted by Rothbaum (1995) using virtual realitygraded exposure to treat acrophobia (fear of heights). The VR treatment was con-ducted over 7 weekly 35–40 minute sessions. A hierarchy of height situations waspresented to each subject in the order determined by each subject’s self-rating oftheir fear of heights. Subjects were exposed to the VR heights scenario and movedto a higher level of anxiety provoking stimuli according to the subjects own timeframe. Pre- and posttreatment questionnaires were administered to the experimen-tal and control groups; the posttreatment questionnaires were administered 8 weeksafter the pretreatment assessment. During treatment the subjects were exposed tothe following virtual heights environments: glass elevator, outdoor balcony, andfootbridges.

Data analysis revealed no pretreatment differences between the treatmentand control groups on any instrument or any demographic variables. Measures ofanxiety, avoidance, distress, and attitudes toward heights decreased significantlyfrom pre-treatment to posttreatment for the treatment group; no differences werenoted for the control group. On a semantic differential scale, the treatment group’sposttreatment mean scores on all attitude questions were below the midpoint, thusindicating positive heights attitudes. The opposite was seen for the control group.Anecdotal reports from 7 of the 10 VR exposure treatment subjects revealed that,without being instructed to do so, the subjects placed themselves in situationsthat exposed them to in vivo heights situations. These anecdotal reports suggestthat the VR exposure treatment was generalizing to the subject’s daily activities.

VIRTUAL REALITY FEAR OF FLYING TREATMENT PROTOCOL

The fear of flying virtual reality exposure therapy conducted in our office isbased on and follows the treatment protocol established by Drs. Rothbaum andHodges in their therapist manual (Rothbaum, 1997). The manual was written toaccompany the “turn-key” VR computer system for fear of flying treatment.

The fear of flying virtual reality exposure therapy that we have conducted isdivided into three discrete segments: 1) Pre-treatment assessment, 2) Treatment,and 3) posttreatment assessment. (Klein, 1999).

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Pre-treatment assessment: The pre-treatment assessment is designed for twospecific, primary purposes. The first purpose is to evaluate each potential fear offlying patient, and to determine his or her appropriateness for treatment. Issuessuch as major depression, for example, may preclude successful involvement intreatment and may need to be treated prior to initiating VR treatment. The secondpurpose of the pre-treatment assessment is to identify the unique aspects of thepatient’s fear of flying. Understanding the elements of the patient’s phobia enablesthe VR treatment to be tailored and individualized for each patient.

A number of standardized, written instruments are administered to eachprospective patient. These instruments are measures suggested by Dr. Rothbaumin her instruction manual (Rothbaum, 1997). These instruments include:Ques-tionnaire on Attitudes Toward Flying—QAF(Howardet al, 1982). This instru-ment consists of 36 items that assesses a history of fear of flying,Fear of FlyingInterview—FOFI (McNally & Louro, 1992). The FOFI is a 33-item instrument,with a 0–8 scale, that helps to differentiate between agoraphobia and simple pho-bia,State-Trait Anxiety Inventory—STAI(Speibergeret al, 1970). This is a 40-iteminventory that differentiates between state and trait anxiety,Self-Survey of StressResponses—SSR(Forgione & Bauer, 1980). These 38 items, using a 0–5 scale,measure fearful responses divided into: Automatic Responses, Muscle responsesand Central Process.Virtual Reality Airplane Scenarios—FOF Study Self-ratings(BO Rothbaum, 1997). These 8 items reflect the VR scenarios that the patient willexperience in the VR exposure therapy.

All of the instruments are not administered to all prospective patients. Basedon an initial telephone interview when the prospective patient calls to schedulean appointment for treatment, a decision is made as to which instruments will beadministered.

Two additional instruments are administered to each patient in the pretreat-ment assessment. These instruments include:Psychological/Social History Ques-tionnaire (Rainwater,1984), a rapid way of obtaining demographic informationabout the patient’s background, and theMinnesota Multiphasic Personality Int-erview—MMPI(Hathaway, S. & McKinley, J., 1948).

Clinical Interview.Prior to beginning VR treatment each patient is seen for aclinical interview. The clinical interview has several purposes. First, material gath-ered during the written portion of the pre-treatment assessment can be discussedand evaluated in greater depth, verifying any concerns and validating any prelimi-nary material. At this time, the therapist is able to establish factors that underlie thepatient’s fear of flying issues and also begin to create an individualized treatmentplan for the patient.

Second, during the clinical interview some feedback regarding the fear offlying issues and other treatment options is provided to the patient. Other treat-ment options, such as medication, are outlined for the patient. During the clinicalinterview the patient is provided in depth information regarding VR exposure

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therapy and an opportunity to see the equipment and ask any questions that mightarise.

Third, once these issues are resolved, the patient contracts for treatment,signs an informed consent form, and any financial issues (payment and insurancereimbursement) are resolved.

VIRTUAL REALITY EXPOSURE TREATMENT

Sessions 1–2/3: Generally patients are seen in treatment on a once a week ba-sis. Prior to beginning the actual VR exposure therapy, patients are first giventraining to deal with the anxiety that they may experience during the VR treat-ment and during an actual flight. During sessions one to three, patients aregiven instruction in traditional relaxation training and thought-stopping. Theactual number of sessions depends on how well the patients are able to masterthe techniques. At the end of each of these initial sessions, patients are given“homework” assignments. They are instructed to practice their relaxation andthought-stopping training at home, at least twice a day. Progress reports areobtained at the beginning of the next session.

Sessions 2/3–until completion: Once the patient displays a moderate success inrelaxation and thought-stopping, the patient is ready to move into the actual VRexposure therapy. The first VR session introduces the patient to the equipmentand the VR experience. For the majority of the patients, there is an initialperiod of time, generally 20–25 minutes, during which the novelty of the VRexperience occurs. The initial scenario is the patient sitting in the cabin of theaircraft, parked at the terminal, engines off, with background music. The patientfirst experiences moving about in their “virtual world” and developing a senseof presence. As the patient moves his or her head up, down, side to side, the“virtual world” moves and changes in synchronicity. If the patient wishes tolook out of the cabin window, they turn their head to the left and, in real time.The image that the patient views shifts from viewing the seat back of the seat infront of the patient, to the wall of the aircraft, until the window fills the field ofview. As the patient move their body closer to the portion of their virtual worldthey wish to examine, that image expands, as it would expand in the real world.The patient is in a “virtual world” that shifted and changed, giving the patienta sense of being immersed in and actively interacting with the “real” world.

Generally, the novelty of the virtual reality experience last approximately20–25 minutes, after that time the patient’s focus shifts from the uniqueness ofexperiencing a virtual aircraft to experiencing the stimuli that arouses some levelof anxiety. These stimuli might be the engine cowling, the wing of the aircraft,or the confines of the aircraft cabin. For each patient the stimulus is unique for

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that individual and triggered associations and memories of previous flights. A fewpatients initially had difficulty in relating to the virtual reality experience. Overthe next session or two, with encouragement, the patient generally becomes lessresistant and begins to identify with various queues, thus immersing themselvesin the virtual environment.

During each session Subjective Units of Discomfort (SUDs) are obtainedfrom the patient at a baseline level and every five minutes during VR treatment.The SUDs rating measures on a 0–100 scale the level of anxiety or discomfort thepatient is experiencing in the virtual aircraft. The SUDs score assists the therapistin individualizing the VR experience for the patient. If their SUDs level increasedmarkedly, the therapist can intervene by suggesting that the patient shift their focusfrom looking out the window to the seatback in front of them and utilize relaxationtechniques mastered during the initial sessions. At the other end of the spectrum,if the patient’s SUDs remain at a low, constant level for a considerable period oftime, it is time to move on to the next VR scenario.

Moving from the first scenario (sitting in the aircraft parked at the terminalwith the engines off) to the second scenario (parked at the terminal, with theengines on) adds a second sensory domain, auditory queues, to the visual stimuli.Sounds appear to have a powerful impact on patients and add significantly to theVR experience for many patients.

During the first two scenarios the aircraft and the patient remains stationary.Scenario three moves the aircraft away from the terminal and to the taxiway.Movement becomes the focus of the VR experience as the patient watches out theaircraft window as the aircraft taxies back and forth along the tarmac.

The next scenario (takeoff, smooth flight and landing) is where patients spentthe majority of their VR treatment. During this phase of treatment, once the patientis comfortable with the smooth flight, treatment usually involves incorporating asmany “touch and goes” (4–5 per session) as we can fit into the session, and asmany as the patient contracts for. In a “touch and go” the aircraft takes off, flies innon-turbulent weather for 3–5 minutes, and then lands; this is repeated over andover. Obviously, this maneuver would be impossible in a real aircraft, and reflectsthe uniqueness and flexibility of virtual reality treatment.

The last scenario (thunderstorm and turbulent flight) is the final stage and,unless the patient’s fear centers on thunderstorms/turbulent flight, the majority ofthe treatment occurs in the previous phase of treatment. Patients comment thatthe thunderstorm is very real and certainly elicits anxious feelings; however, fora number of patients the thunderstorm scenario seems almost anticlimactic. Theyhave accomplished the takeoff, flight and landing, and once they have “passed” thisstage they feel much more secure in their ability to accomplish an in vivo flight.

Paralleling the VR treatment are homework assignments that patients need toaccomplish between treatment sessions. These homework assignments are crucialand are designed to assist in generalizing their VR experience to the real world.

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Table I. Typical Virtual Reality Scenarios for Fear of Flying Treatment

1. Sitting in aircraft cabin with engines off (visual cues only)2. Sitting in aircraft cabin with engines on (visual and auditory cues)3. Aircraft pulls away from terminal and taxis (movement added to above cues)4. Takeoff, smooth flight, and smooth landing (“touch and goes”) or extended smooth, level flight5. Thunderstorm/Turbulent flight—from and back to smooth flight

(Klein, 1999).

Homework assignments include tasks such as visiting the airport and watchingaircraft take off and land; going to the airport and just sitting in the airport, takingin the sights and sounds of the airport experience; or calling the airlines or theirtravel agent in order to simply gather information about a proposed flight, sometime in the future. The focus of treatment and of the homework assignments is togradually move the patient toward taking an actual flight.

Over the course of treatment patients who began VR exposure therapy re-vealed reductions in every measure of anxiety and fear related to flying. In addi-tion, self-statements about flying also changed as the patient progressed thoughthe VR treatment. However, unless these factors can translate into actual changesin behavior, the changes did not meet the ultimate criteria: Is the patient able toactually fly after treatment? In order to move the patient toward this goal, thetherapist suggests, supports and encourages the actual goal of a short flight (20–30minutes duration) as a final goal the patient should be “keeping in mind” as theymove through the various aspects of VR treatment. This goal is not mandated as arequirement of treatment, nor would the patients be considered a failure if they didnot accomplish this in vivo flight. The goal of an actual flight is introduced earlyin treatment, communicating that an actual flight will help the patient accomplishthe stated goal and will assist in making this anticipated change in behavior morepermanent (see Table I).

CASE STUDY

Sue∗ is a married, 47-year-old, teacher who had been unable to fly for over 10years when she sought treatment through my office, in October 1998. According toher accounting of the circumstances that led up to her inability to fly, approximatelyfive years previously she described a flight where she “. . . went through a tornadoor something like that.” For a number of years subsequent to this flight she wouldavoid flying, at any cost. Sue also indicated that in addition to her fear of flyingshe also experienced fear of driving over bridges, overpasses, freeways, and aninability to travel independently away from a very circumscribed area (2–3 miles)around her home or place of work.

∗Names and some descriptive data modified to protect confidentiality of individuals.

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Pre-assessment of VR airplane scenarios revealed significant SUD elevationsin all aspects of flying, but specifically takeoff and turbulent flight. Areas of leastdiscomfort were reflected in smooth flight and landing.

Treatment was initiated by instructing Sue in breathing/relaxation techniquesprior to introducing her to the VR exposure therapy. This was conducted overa period of two sessions, with measurements of successful relaxation (0–10,with 10 indicating maximum relaxation; Sue’s scores of approximately 8, bothat home and in the office, reflected successful incorporation of relaxation tech-niques. Sue was requested to practice her relaxation at least twice a day for15–20 minutes per session. During session three Sue was instructed in thoughtstopping techniques in order to assist her in reducing anticipatory worry andanxiety.

In session four, Sue experienced her first VR exposure therapy session. Priorto the session she stated that she felt some initial anxiety in the waiting room;however, once in the therapy room she indicated that she felt fine and did notexperience any anxiety. In fact, her SUDs were “0” throughout the entire session.Sue commented that the VR felt real but she was simply not anxious or upset. Formany FOF patients, there is an initial period of novelty and curiosity, interactingor the first time with the VR equipment.

For Sue it was not until the following session, where auditory queues—thesound of the jet engines spooling in the background—began to elicit actual mem-ories of her previous flight. Sue reported that she felt “butterflies” in her stomach,increased heart rate, shortness of breath, and feeling hot. Sue had immersed herselfin the VR environment and developed a sense of presence that activated her fearresponse.

In session 7, Sue felt that she was ready for the next phase in her VRtreatment—a virtual flight. After a 10 minute flight we landed and then prac-ticed another takeoff and smooth flight. Sue’s comments during the flight werethat the flight felt more real, “. . . not in the office, I’m on a plane to Florida.”

Unfortunately Sue’s driving fears and anxieties began to escalate and alsoher anxiety during the VR sessions also increased significantly. Her fears reacheda point where she was almost immobilized and unable to drive. At this junctureSue and I felt that we needed to put the VR sessions on hold and work intensivelyon reinforcing her relaxation training and assisting her in re-establishing controlover her emotions. In retrospect, Sue had been moving very rapidly through theVR program and had discussed plans for an actual flight within a month or so.Perhaps she had moved too rapidly through the VR program, not allowing suf-ficient time to master the relaxation techniques and to allow the fear stimuli tohabituate.

For the next several sessions, our focus shifted from fear of flying to herfear of driving and the need to reassert control over her fears. When Sue feltthat she was “in control” once again and was able to return to her previous level

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of functioning, including driving, VR therapy was reinitiated. For the next eightsessions we practiced takeoffs and landings, while Sue made more frequent tripsto the airport. After moving into the last level in the VR hierarchy—a turbulentflight and thunderstorm, Sue felt ready to schedule an actual flight.

The following week Sue returned to my office to report on her flight. Dur-ing the flight Sue was requested to fill out a test flight self-monitoring sheet thatrecorded SUDs during pre-boarding, pre-take off, 5 minutes after take off, duringthe flight, landing, and post-landing. Her highest SUDs level, “30” occurred dur-ing pre-boarding, in anticipation of the flight; however, after take off her SUDsdiminished to “15,” 5 minutes after take off, to “3” during the flight, and “0” duringpost-landing. Sue reported several delays prior to the flight that tended to increaseher anxiety; however, by focusing on her relaxation techniques she was able toget through these unexpected situations and through the actual flight. Sue reportedthat she felt very much improved and that she felt she had conquered her fear offlying.

Over the succeeding months, Sue has flown several times. Each successiveflight has been more successful for her and has assisted her in internalizing thebelief that she is able to fly without fear or anxiety. SUDs ratings of VR airplanescenarios, almost 1 1/2 years after Sue initiated reflect almost complete absence offear or anxiety associated with flying.

CONCLUSIONS

Virtual Reality exposure therapy is emerging as a valid technique for treat-ing fear of flying disorders. Several studies have shown the benefit in treatingsimple phobias, with the benefits of treatment continuing six months posttreat-ment (Rothbaum, 1995). Virtual Reality treatment is also time- and cost-efficientas compared to in vivo treatment. From the patient’s perspective, Virtual Realityexposure therapy should be more comfortably accepted for a number of reasons.Unlike in vivo treatment, all aspects of Virtual Reality exposure therapy can becontrolled; thereby, reducing feelings of powerlessness. If the patient becomesanxious in a Virtual Reality session the therapist can immediately shift to a lessanxiety-provoking scenario. Or, if the anxiety level is intolerable, the patient cansimply remove the HMD. In addition, since the treatment is conducted totally inthe therapist’s office, confidentiality can be assured.

Current Virtual Reality exposure treatments have been developed to treatfear of flying, fear of heights, spiders, public speaking, and PTSD. As researchcontinues in Virtual Reality treatment additional psychological conditions will beexplored as to the efficacy of Virtual Reality treatment. It is exciting to envisionthe possibilities in psychotherapeutic assessment and treatment that Virtual Realitymay bring to therapists in the near future.

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Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970).Manual for the State-Trait AnxietyInventory (self-evaluation questionnaire). Pale Alto, CA: Consulting Psychologists Press.

Strickland, D. (1996). A virtual reality application with autistic children. PRESENCE: Teleoperatorsand Virtual Environments,5, 319–329.

Documents

Virtual Reality Exposure Therapy in the Treatment of Fear of Flying