Introduction

Christina sat in my office shaking and crying as she talked about wanting to fly to her best friend’s wedding. “I’ve known her all my life. I promised I would be there for her, but it means I have to fly, and I just can’t!” The wedding was only three weeks away and Christina was frantic. She desperately wanted to overcome her fear of flying but wasn’t sure it was even possible. 

Normally poised and professional, when faced with the prospect of getting on a plane she began hyperventilating, crying, and feeling nauseous. Sometimes she vomited. She had refused promotions if they required business travel, but she wasn’t willing to miss the most important day of her friend’s life.

Luckily, I had an answer. 

For years, I had treated anxiety using cognitive-behavioral therapy (CBT) combined with mindfulness, acceptance, relaxation, guided imagery, and other interventions. Treatment results were generally good, but I had recently read about a technological breakthrough: virtual reality therapy (VRT). Christina’s face lit up when I told her about it.

First, Christina learned about the cycle of anxiety and how to break it. She practiced diaphragmatic breathing, identified and explored her fears, and gathered the information she needed to combat them. She learned that flying was safe, even when turbulent. “I know the plane’s not really going to fall out of the sky and I’m not going crazy, but I’m still really nervous every time I think about getting on a long flight, especially if it’s rainy, or bumpy, or dark and I can’t see outside.” 

We discussed that you may know something intellectually, but it’s hard to really "know it" on a gut level until you have experienced it and that virtual reality (VR) could give her that experience. She was nervous, but excited and ready to try. 

Because Christine got scared “before I even get to the airport”, I had her start by riding to the airport in a virtual taxi. She practiced voicing her fears and talking back to them while using her relaxation skills. I coached her and monitored her anxiety level which went from 6 on a scale of 0-10, down to 1. At this point she announced, “I’m ready to go into the airport.” 

Waiting at the gate was easier than she expected. Next, she moved down the virtual jetway to her window seat. After only two repetitions, she felt ready to fly. 

Her first virtual flights were in daylight with clear skies. As her comfort increased, I had her “flying” at night, and finally through bumpy nighttime storms. After three sessions of virtual flights, her anxiety stayed between 0-2 regardless of the weather. “I feel ready.”

Her exuberant email arrived two weeks later: “I did it! There were even some bumps, but they didn’t really bother me. I couldn’t have done it without the virtual reality. Thank you, thank you, thank you!”

Why This Book Was Written

“This is life changing. Thank you!”

Helping Christine and similar clients has made me a passionate advocate for VR therapy. I am not alone; many other therapists have similar examples of using VR in creative ways to help clients. 

VR is a technological breakthrough for therapy—especially for anxiety. This guide is written by clinicians for clinicians so that you—and your clients—can experience the benefits of VRT based on clinical experience, research findings, and case examples.

Although I have specialized in treating anxiety disorders for 40 years, I would have never predicted that I might become an expert in using VR. In 2008, I read an article that changed my life: Parsons and Rizzo (2008) said that exposure in VR was as effective as in vivo exposure—the gold standard for anxiety treatment. That got my attention and a literature review in 2009 cemented my interest. I started using VR with clients in 2010 and seeing great success. In the intervening years, I have taught continuing education workshops, spoken at conferences, consulted with therapists about adding VR to their practices, and written about VR. 

My collaborator, Debra Boeldt, PhD, is a licensed psychologist, Deputy Director of the National Mental Health Innovation Center, and another advocate for VR. She has peer-reviewed publications to her name, speaks at conferences nationwide about VR, and supports the Tech Innovation Network.

Practical

This book provides a practical guide to integrating VR for anxiety into your practice in ways that are easy to understand and apply. It explains VR’s benefits and uses, reviews key research, answers common questions, and addresses common concerns. It covers using VR in person, for teletherapy, and for client homework.

Recommendations are informed by clinical experience as well as research. Case examples and quotations illustrate ways to use VR in clinical settings. Names and identifying details have been changed to protect client privacy and confidentiality, but all are based on actual people who sought help for anxiety. 

Chapter 2 presents a general model of anxiety and its treatment. Chapters 3 and 4 describe therapeutic uses of VR followed by a VR anxiety treatment protocol and case example in Chapter 5. Chapter 6 provides an overview of VRT for specific phobias. VRT for blood-injection-injury phobia, claustrophobia, driving phobia, flying phobia, height phobia, and insect and animal phobias is discussed in Chapters 7 through 12. VRT for panic disorder and agoraphobia is covered in Chapter 13, social anxiety disorder in Chapter 14, stress, tension, and insomnia in Chapter 15, PTSD in Chapter 16, and for generalized anxiety disorder, obsessive-compulsive disorder, and illness anxiety disorder in Chapter 17. Chapters 18 through 20 discuss how VR can be used with non-CBT therapies, provide answers to  frequently asked questions, and discuss likely future developments. Appendix A explains types of VR equipment and content and Appendix B is a Virtual Reality Therapy Checklist.

Anxiety Focus 

Anxiety is used as an umbrella term embracing all its clinical and subclinical manifestations ranging from tension, insomnia, or stress through panic attacks, phobias, intrusive worries, obsessions and/or compulsions, and post-trauma symptoms. VR can also be used for issues outside the scope of this book such as eating disorders, body image, social skills, increasing empathy, etc. 

VR can be used for multiple purposes at different stages of anxiety treatment. Client responses to virtual stimuli can help confirm a diagnosis or evaluate treatment effectiveness. VR can facilitate relaxation, skills training, and skills practice, as well as be used for exposure, reinforcement, relapse prevention, and homework. 

Integrative Approach

I use an integrative approach to treatment grounded in a comprehensive model of anxiety (Chapter 2). My background includes training in (listed alphabetically) assertiveness training, behavior therapy, client-centered therapy, cognitive therapy, cognitive-behavioral therapy, dialectical behavior therapy, ego state therapy, existential therapy, exposure therapy, eye movement desensitization and reprocessing, family systems therapy, gestalt therapy, guided imagery, hypnosis (directive and Ericksonian nondirective), mindfulness, motivational interviewing, positive psychology, psychodynamic therapy, rational-emotive therapy, relaxation techniques, solution-focused brief therapy, stress management, stress inoculation training, and other approaches. 

I believe in treating the whole person. I have seen skilled professionals get good clinical results using many different techniques. In my experience, the most successful therapists use a combination of approaches flexibly adapted to each individual client. 

Research Support

I also believe in research-informed practice. Quality research advances our knowledge. Incorporating new knowledge into practice increases efficacy. Human beings are complex, and it helps to be able to view clients through different theoretical lenses and to have as many tools in your toolkit as possible. VR is a flexible, research-tested tool deserving a place in your clinical armamentarium. 

Interested readers can learn more about the relevant research by exploring the studies cited in the “Evidence Base” section of most chapters. 

What Is Virtual Reality?

“After a few minutes, it began to feel real.” 

Virtual reality (VR) creates a 3-dimensional world. When a client dons a VR headset, they enter a virtual environment (VE) that surrounds them. As they turn around or move, the images they see change appropriately, as if they were in a real place. Views of the actual environment are blocked; clients are immersed in a virtual environment. This sense of immersion is part of what makes virtual experiences convincing.

Clients may have a virtual body (avatar) within the VE. Have clients physically mirror their avatar’s body position and movements. This deepens clients’ sense of presence or feeling as if they are truly present in the VE. 

Sounds appropriate to the VE are played through the headset (or a phone held in the headset). Some VEs allow clients to move (or be transported) to different places within the virtual world. 

Therapy-specific products allow the therapist to control and monitor the client’s virtual experience using a therapist workstation computer or tablet device. You have a 2-D view of the VE and can see what clients are doing and where they are looking. 

Additional equipment can be used to make clients’ VR experience more convincing. Some examples include: 

• Hand-held controllers that enable clients to interact with virtual objects or move within the VE. Some controllers provide haptic (tactile) feedback.

• Specialized devices such as a steering wheel and pedals for driving simulations or simulated weapons for treating war-related posttraumatic stress disorder.

• Vibrating platforms that add kinesthetic stimuli by mimicking the vibrations on an airplane or a bomb exploding.

• Scents such as alcohol (for substance abuse treatment) or gunpowder (for war-related PTSD).

When selecting VR products, look at the specific contents of each VE included in the product. Consider which VEs you might use most often in your clinical practice. Consider VE content and potential applications, not just the VE title or its intended purpose. This is discussed in more detail in “VR Product Questions” in Chapter 19. For more information about VR equipment and content types, see Appendix A.

Do Clients Respond to VR?

You might expect that clients would not respond to VR. After all, they know they are sitting in your office. They know they just put on a headset. Research says that most clients do respond (Cardoş et al., 2017; Carl et al., 2019; Diemer et al., 2016; Garcia-Palacios et al., 2007; Maples-Keller et al., 2017; Wechsler et al., 2019). 

What do clients say? The most common response to entering VR is “Wow!” And the most common response afterward is “I didn’t expect it to be so real.”

Here are samples of frequent client comments: 

• “This is cool!”

• “I didn’t think I would react to it so strongly.”

• “That’s AMAZING!”,

• “It’s really working. I feel much less scared than I did at first.”,

• “I’m a lot farther than I thought I would be at this point in therapy.”

• “Things that used to be hair-raising are perfunctory.”

• “I think VR is really fun. It’s a good way to get over things.”

Do Clients Accept VR?

Client interest and acceptance of VRT is extremely high. At least half my clients come specifically requesting VR therapy. Would-be clients from around the country call asking how to find clinicians offering VRT. 

Can VR Be Used in Teletherapy?

Yes, certain VR systems (not all) are compatible with teletherapy and allow you to control and monitor your client's virtual experience from a distance. I have found that teletherapy works very well and has some advantages, although there can be technical challenges. 

Clients need a VR headset (or smartphone and headset/holder combination) that is compatible with your VR system and a reliable internet connection. The company that produces your VR system will have detailed instructions about what equipment a client needs and how to use it.

I strongly recommend having a video connection during VR teletherapy sessions so you can observe how your client responds and what they do. Clients tend to move when standing in VR. You want to observe and minimize any chance of clients tripping or bumping into things.

If you are considering using VR during teletherapy, follow the standard ethical and risk management teletherapy guidelines such as getting teletherapy informed consent and knowing where clients are, how to contact them, and what the local crisis services are. 

Agree ahead of time on what to do if there are technical issues. Consider whether any negative reaction to VR or VR exposure can be safely and appropriately handled remotely.

Virtual Reality “Therapy”?

VR is a powerful tool with numerous clinical applications, including but not limited to exposure or virtual reality exposure therapy (VRET) (Gonçalves et al., 2012; Parsons & Rizzo, 2008b; Powers & Emmelkamp, 2008). Virtual reality therapy (VRT) includes all therapeutic uses of VR.

Despite what the term virtual reality therapy seems to imply, VR is a tool—not a treatment. VR experiences are not inherently therapeutic. Therapist skills and knowledge remain the key ingredients, but VR can increase the impact of those skills.

Goals 

The purpose of this guide is to help you: 

• Understand anxiety and guide treatment using an anxiety model that is easy to explain to clients and helps prepare them for therapy.

• Incorporate VR into anxiety treatment for relaxation, skills training and practice, reinforcement, and exposure therapy.

• Learn how VRT works in practice based on a VR treatment protocol and multiple case examples.

• Use VR to treat a range of anxiety disorders.

• Integrate VR with therapies other than CBT.

• Answer clinical and practical questions.

References

Cardoş, R. A. I., David, O. A., & David, D. O. (2017). Virtual reality exposure therapy in flight anxiety: A quantitative meta-analysis. Computers in Human Behavior, 72, 371–380. https://doi.org/10.1016/j.chb.2017.03.007

Carl, E., Stein, A. T., Levihn-Coon, A., Pogue, J. R., Rothbaum, B., Emmelkamp, P., Asmundson, G. J. G., Carlbring, P., & Powers, M. B. (2019). Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials. Journal of Anxiety Disorders, 61, 27–36. https://doi.org/10.1016/j.janxdis.2018.08.003

Diemer, J., Lohkamp, N., Mühlberger, A., & Zwanzger, P. (2016). Fear and physiological arousal during a virtual height challenge—effects in patients with acrophobia and healthy controls. Journal of Anxiety Disorders, 37, 30–39. https://doi.org/10.1016/j.janxdis.2015.10.007

Garcia-Palacios, A., Botella, C., Hoffman, H., & Fabregat, S. (2007). Comparing acceptance and refusal rates of virtual reality exposure vs. in vivo exposure by patients with specific phobias. CyberPsychology & Behavior, 10(5), 722–724. https://doi.org/10.1089/cpb.2007.9962

Gonçalves, R., Pedrozo, A. L., Coutinho, E. S. F., Figueira, I., & Ventura, P. (2012). Efficacy of virtual reality exposure therapy in the treatment of PTSD: a systematic review. PLoS ONE, 7(12), e48469. https://doi.org/10.1371/journal.pone.0048469

Maples-Keller, J. L., Yasinski, C., Manjin, N., & Rothbaum, B. O. (2017). Virtual reality-enhanced extinction of phobias and post-traumatic stress. Neurotherapeutics, 14(3), 554–563. https://doi.org/10.1007/s13311-017-0534-y

Parsons, T. D., & Rizzo, A. A. (2008a). Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: A meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry, 39(3), 250–261. https://doi.org/10.1016/j.jbtep.2007.07.007

Parsons, T. D., & Rizzo, A. A. (2008b). Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: A meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry, 39(3), 250–261. https://doi.org/10.1016/j.jbtep.2007.07.007

Powers, M. B., & Emmelkamp, P. M. G. (2008). Virtual reality exposure therapy for anxiety disorders: A meta-analysis. In Journal of Anxiety Disorders (Vol. 22, Issue 3, pp. 561–569). Pergamon. https://doi.org/10.1016/j.janxdis.2007.04.006

Wechsler, T. F., Kümpers, F., & Mühlberger, A. (2019). Inferiority or even superiority of virtual reality exposure therapy in phobias?—A systematic review and quantitative meta-analysis on randomized controlled trials specifically comparing the efficacy of virtual reality exposure to gold standard in vivo exposure in agoraphobia, specific phobia, and social phobia. Frontiers in Psychology, 10. https://doi.org/10.3389/fpsyg.2019.01758