Chapter Abstracts

Chapter 1: Introduction

This guide written by clinicians for clinicians offers therapists a roadmap for integrating virtual reality (VR) into their practice that combines research support and practical experience. A flying phobia case example opens Chapter 1 and illustrates how VR facilitates multiple aspects of anxiety treatment. The author’s credentials and those of her collaborator are presented, followed by a description of their approach to adding virtual reality therapy (VRT) and virtual reality exposure therapy (VRET) into the reader’s clinical practice using a comprehensive anxiety model and an integrative approach to treatment. Important initial questions are answered: What is VR? Do clients respond to VR? Do clients accept VR? Can VR be used in teletherapy? Chapter 1 concludes with a summary of the book’s goals.

Section I: Anxiety Treatment Overview 

Chapters 2 through 5 give readers an overview of virtual reality therapy (VRT) for anxiety. Chapter 2 introduces a flexible, comprehensive model for understanding and explaining anxiety disorders and their treatment. In Chapter 3, readers learn how virtual reality (VR) can be used in teletherapy as well as in-person sessions for a broad range of therapeutic interventions (other than exposure). Chapter 4 focuses on the use of VR for individualized, controlled exposure, known as virtual reality exposure therapy (VRET), and answers common therapist concerns about exposure and VRET. Chapter 5 presents a VRT treatment protocol from the initial phone screening and diagnostic interview through relapse prevention and termination using a case example transcript from a 7-session treatment of a woman with panic disorder with agoraphobia, specific situational phobia (claustrophobia), and discrete social anxiety disorder. 

Chapter 2 Anxiety Cycle Model

Chapter 2 describes a flexible, comprehensive model of anxiety and its treatment, illustrated with diagrams. The model discusses five anxiety triggers, factors that predispose clients to develop anxiety or that trigger clinical or subsyndromal anxiety symptoms. The anxiety triggers include genetic predisposition, chemical or biochemical influences, external stress, negative self-talk and/or unrealistic self-demands, and unhelpful lesson from past events that the client experienced, observed, or heard about. These triggers activate physiological, emotional, and cognitive responses which, in turn, result in fear-motivated behaviors that create and maintain a vicious cycle of anxiety. 

Using this anxiety cycle model helps therapists make differential diagnoses and structure treatment, including when and how to use virtual reality. This model also helps clients understand how their personal experiences fit the cycle of anxiety, normalizes clients’ experiences, and makes it easier for clients to understand the rationale behind treatment interventions like exposure therapy and eliminating safety behaviors. 

Chapter 3: Uses of VR in Anxiety Treatment

Chapter 3 explains multiple uses for virtual reality—other than exposure—in treating anxiety, either in the office or via teletherapy. Uses include facilitating relaxation and calm, teaching anxiety management skills, uncovering fears or confirming diagnoses, practicing other skills, confirming treatment efficacy, providing pleasurable reinforcing experiences, preventing relapse, and homework including home practice. 

VR can help clients learn and practice skills to manage anxiety, such as diaphragmatic breathing, progressive muscle relaxation (PMR), mindfulness, and/or imagery. Suggestions are given to help therapists determine which anxiety management skills will be most effective for different clients and concerns. Explanations are illustrated by case examples.

Chapter 4: VR Exposure Therapy 

Virtual reality exposure therapy (VRET) is the best-known use of virtual reality (VR) in anxiety treatment and an incredible tool for helping clients overcome fears. Therapists can offer safe, private, controlled, individualized, vividly evocative, repeatable exposures during sessions without leaving the office. Readers learn the rationale for exposure, get an overview of the research support for exposure and VRET, and explore the benefits of VR exposure versus other exposure options. Common therapist concerns about exposure and/or VRET are addressed. 

The chapter explains where exposure fits within a comprehensive model of anxiety treatment. Readers are taken step-by-step through a process to prepare clients for successful VRET by creating a shared understanding of anxiety and its treatment, teaching anxiety tolerance skills, identifying and countering clients’ fears, explaining the rationale for exposure, and obtaining permission. The importance of a collaborative, therapeutic alliance that empowers clients as active partners in their own recovery and of therapist willingness to adapt treatment to client needs are stressed. Readers learn ways to track clients’ symptoms and fear levels, create hierarchies of virtual scenarios, implement exposure, monitor treatment progress, and prevent relapse.  

Chapter 5: VR Anxiety Treatment Protocol

In this chapter, readers are taken through an entire course of virtual reality therapy (VRT) from pre-intake screening call through final session. This case example of an adult female client with panic disorder with agoraphobia, claustrophobia, and discrete social anxiety disorder (fear of public speaking) is presented as an example of a virtual reality treatment protocol. The process of explaining and planning VRT is outlined. Readers see how virtual reality (VR) is used for different purposes at different points throughout the therapy process. 

Virtual experiences helped the client relax and learn diaphragmatic breathing and gave her a safe place to practice new skills, face fears, and grow in mastery and confidence. Using VR, the therapist arranged a series of controlled in-session exposure experiences that would not otherwise have been possible. The client was able to face panic-inducing situations that she had been avoiding. In session, she practiced speaking before virtual audiences, virtually entering enclosed spaces, and taking virtual airplane flights. 

Section II: Treating Fears and Phobias 

Section II prepares the reader to incorporate virtual reality (VR) into treatment for common specific phobias. Chapter 6 provides an overview of how specific phobias fit the anxiety cycle and treatment model, how virtual reality therapy (VRT) supports treatment for specific phobias, answers to common questions about treatment, and the evidence base for VRT of phobias. 

Each of the following chapters focuses on common specific phobias. Chapter 7 reviews VRT for blood-injection-injury phobia. Chapter 8 explores VRT for claustrophobia. Chapter 9 covers VRT for driving phobia. Chapter 10 addresses VRT for flying phobia. Chapter 11 examines on VRT for height phobia. Chapter 12 discusses VRT for animal and insect phobias. Each chapter analyzes the components of the phobic cycle of anxiety and treatment. Common comorbidities and issues of differential diagnosis are addressed where relevant. Case examples bring the theoretical presentations to life. Each chapter closes with a summary of key research findings.

Ch 6: Specific Phobias Overview

Chapter 6 presents an overview of the ways therapists use virtual reality (VR) when treating specific phobias. The chapter opens with a review of the different factors that can contribute to the creation and maintenance of specific phobias. Mapping the client’s phobia onto the anxiety cycle model presented in Chapter 2 helps explain and normalize the client’s experience. It also helps therapists prepare clients for treatment and choose those virtual experiences most likely to be therapeutic. 

VR can assist treatment in different ways at different stages. Peaceful virtual environments (VEs) can induce or deepen relaxation and calm. Anxiety management skills can be taught and practiced in VR making the experience more immersive and engaging. VR can be used for gradual exposure. Client responses to VR can uncover fears or skill deficits. VR can be used to track the effectiveness of treatment and minimize relapse. The issue of treating a client with multiple phobias is addressed as is the challenge of what to do when the available VEs do not include the client’s specific phobic triggers. The chapter concludes with a summary of the relevant research.

Ch 7: Blood-Injection-Injury Phobia 

This chapter covers the uses of virtual reality (VR) in treating multiple forms of blood-injection-injury (BII) phobia. Clients with this phobia often avoid vaccinations and postpone or avoid needed mental or dental care. Female clients may dread the medical procedures involved in pregnancy or fertility procedures such as in vitro fertilization. The chapter explains how to apply the anxiety cycle model (explained in Chapter 2) to BII phobia, how to distinguish this phobia from common comorbid conditions, and what virtual reality therapy (VRT) of BII phobia may involve. 

Several common fears and misconceptions are addressed. Treatment challenges are examined including clients who faint, finding relevant VR material, addressing the realistic likelihood of pain, and working to prevent relapse. Applied muscle tension can help clients who actually faint as a result of BII phobia. A case example of successful VRT illustrates the principles discussed in the chapter. 

Ch 8: Claustrophobia 

Clients with claustrophobia tend to fear any situation they cannot easily or immediately leave. Chapter 8 explores how virtual reality therapy (VRT) supports treatment. Common anxiety sensations and common fears are examined. A model of anxiety (explained in detail in Chapter 2) helps clients understand and explain claustrophobia and its treatment. The chapter describes how therapists can use virtual reality (VR) in treatment to deepen relaxation and self-soothing, to foster skill learning and practice, to support acceptance, and for exposure and desensitization.

The chapter addresses such treatment challenges as questioning whether a client’s fear is warranted, dealing with clients who are anxious about donning the VR headset, and ways to use VR if your VR system does not have virtual environments specifically created for claustrophobia. The chapter closes a case example illustrating VRT for claustrophobia and ends with a brief review of some key research. 

Ch 9: Driving Phobia 

This chapter discusses how to incorporate virtual reality (VR) in the treatment of driving phobia, a common fear that severely restricts people’s lives. The chapter begins by exploring how driving phobia can be understood and addressed using a comprehensive model of anxiety (presented in Chapter 2). By identifying the client’s anxiety triggers, anxiety sensations, phobic fears, and resultant actions and mapping these onto the pathological cycle of anxiety, the therapist is able to normalize, validate, and explain the client’s experience. Learning about the anxiety cycle helps clients understand the rationale behind treatment interventions, including virtual reality exposure therapy (VRET), and strengthens client hope and motivation. 

The chapter goes on to present a variety of ways, apart from exposure, that VR can contribute to successful treatment. Readers receive guidance on how to prepare clients for successful VRET. Three case examples explore in depth the applications of VR, highlight VR’s power as a therapeutic tool, and address the many factors that influence treatment response. The chapter ends with a review of the relevant research literature.  

Ch 10: Flying Phobia 

Flying phobia, also called aviophobia, may be the specific phobia that causes the greatest number of clients to seek treatment. Unwillingness to fly limits clients’ educational options, job opportunities, ability to see family and friends, and vacation choices. Every area of clients’ lives can be impacted. The good news is that flying phobia can be treated, and virtual reality (VR) facilitates treatment. VR offers the valuable ability to practice flying during sessions. This chapter guides readers through understanding flying phobia and structuring treatment using a flexible, comprehensive model of the anxiety cycle (explained in Chapter 2). Common anxiety triggers, sensations, fears, and fear-based actions are reviewed. After taking readers through the process of making a differential diagnosis and discusses common comorbidities, the chapter presents the various ways that VR can be used in treatment. Pros and cons of various VR options are explored. The process of providing virtual reality exposure therapy (VRET) is described along with ways to monitor client response and progress and optimize virtual exposure. Guidance is given on self-guided virtual exposure between sessions. Two case examples vividly illustrate successful VRT for flying phobia, after which the chapter closes with a brief review of the research.

Ch 11: Height Phobia 

Chapter 11 focuses on height phobia (acrophobia) and how virtual reality (VR) can be useful in treating this anxiety disorder. The chapter explains how height phobia fits the cycle of anxiety (presented in Chapter 2) by reviewing the anxiety triggers, anxiety sensations, fears, and fear-motivated actions that are commonly found in fear of heights. Differential diagnosis and frequent comorbidities are discussed. Various applications of VR are presented focusing on how VR can help break the client’s anxiety cycle at each point. The use of VR for individualized exposure, called virtual reality exposure therapy (VRET), is described. VRET is described in detail in Chapter 4. Self-help VR apps for height phobia may be an early intervention or be used adjunctively to support treatment. Suggestions are given on how to respond to three frequently encountered treatment challenges. Two case examples illustrate the applications of VR. The chapter closes with an overview of the research on VR therapy for height phobia.

Ch 12: Insect and Animal Phobias 

People can develop a phobia of almost any living creature: bees, birds, cats, cockroaches, dogs, snakes, spiders, and so on. The chapter opens by explaining how insect and animal phobias fit the cycle of anxiety introduced in Chapter 2. It then moves on to describe various ways therapists can use virtual reality (VR) in reducing the phobic triggers, coping with anxiety sensations, uncovering, and challenging phobic fears, and stopping fear-based actions through virtual reality exposure therapy (VRET). Various treatment challenges are discussed with suggested interventions. Three case examples demonstrate the uses of VR: one case of spider phobia (arachnophobia), one case of a phobia of both spiders and insects (entomophobia), and one case of dog phobia (cynophobia). Finally, the evidence base for VRET with spider or insect phobias is presented.

Section III: Treating Other Anxiety Disorders 

Chapters 13 through 17 cover uses of virtual reality (VR) with anxiety disorders other than specific phobias. Chapter 13 discusses virtual reality therapy (VRT) for panic disorder with or without agoraphobia. Chapter 14 focuses on uses of VR in treating social anxiety disorder, including public speaking fears. Chapter 15 presents VRT interventions for common anxiety-related complaints of stress, tension, and/or insomnia. Chapter 16 explores VRT for PTSD. Chapter 17 addresses how VR can be used in treating generalized anxiety disorder (GAD), obsessive compulsive disorder (OCD), and illness anxiety disorder. Each chapter includes one or more illustrative case examples and ends with a summary of the evidence supporting VRT. 

Ch 13: Panic Disorder and Agoraphobia 

Chapter 13 describes how virtual reality (VR) can contribute to effective treatment of panic disorder and agoraphobia. VR can be particularly helpful for clients who struggle with agoraphobia. These clients are often too afraid to face their feared situations in real life. For clients who feel unable to come to the office, virtual reality therapy (VRT) can be offered via teletherapy if clients have the necessary equipment. 

The comprehensive model of anxiety and its treatment introduced in Chapter 2 is used to help readers diagnose and understand panic disorder and agoraphobia and to plan and structure treatment. Readers then see how various applications of VR, described in Chapters 3 and 4, are specifically used when treating fear of panic and agoraphobic avoidance. The chapter also describes ways to incorporate interoceptive exposure with virtual reality exposure therapy (VRET). Two case examples demonstrate VRT for panic disorder and agoraphobia and the chapter ends with a brief review of the research evidence supporting the acceptability and effectiveness of using VR for these conditions. 

Ch 14: Social Anxiety Disorder 

In Chapter 14, readers discover how virtual reality (VR) can contribute to the successful treatment of social anxiety disorder. Social anxiety can be generalized or limited to situations such as those involving public speaking or performing before others. A comprehensive model of anxiety (explained in Chapter 2) helps readers understand the factors that can trigger social anxiety or predispose clients to develop it. Common physiological sensations, fears, and fear-based actions are reviewed including perfectionistic self-demands, self-judging, and post-event processing. 

The chapter describes multiple virtual reality therapy (VRT) interventions and experiences that feel immediate, evocative, and real to clients. In VR, a client can interact with virtual others, while the therapist controls how these virtual people respond to the client, monitors the client’s anxiety level, and observes the client’s actual behavior. VR provides a vivid, yet safe, environment to learn new skills and overcome old fears. Two case examples illustrate various uses of VR in therapy. The chapter ends with a brief overview of the research on virtual reality exposure therapy (VRET) for social anxiety and/or public speaking anxiety.

Ch 15: Stress, Tension, Insomnia 

Chapter 15 explores the applications of virtual reality therapy (VRT) for distressing symptoms of stress, tension, or insomnia. These issues may be a client’s primary complaint or may accompany other anxiety disorders or mental health issues. These symptoms present frequently in clinical practice, especially for therapists who work in behavioral medicine, primary care, pain programs, rehabilitation, or with the elderly or medically ill. The chapter begins by explaining how to map these symptoms onto the anxiety cycle model (explained in Chapter 2) and explore common triggers, sensations, fears, and unhelpful actions. 

Specific ways in which virtual reality (VR) can help relieve stress, tension, and insomnia are presented. Two common treatment challenges are discussed. The chapter concludes with three case examples of VRT for stress, tension, and insomnia. 

Ch 16: Posttraumatic Stress Disorder (PTSD) 

In Chapter 16, readers learn how virtual reality (VR) can assist the treatment of posttraumatic stress disorder (PTSD). Various factors are reviewed that predispose someone to developing PTSD. The chapter presents an overview of PTSD and PTSD treatment using a comprehensive model of anxiety (presented in Chapter 2) that incorporates triggers, sensations, common fears and thoughts, and fear-based actions. Virtual reality therapy (VRT) for PTSD may include using immersive VR to create a sense of safety, to help clients learn or practice self-calming, grounding, distress tolerance, relaxation, or mindfulness skills. These skills are explained in more detail in Chapter 3. VR can be used to provide controlled exposure known as virtual reality exposure therapy (VRET). Details of VRET are discussed in Chapter 4. 

The latter portion of the chapter addresses treating the triggers, sensation, common fears, and fear-based actions common to PTSD and how VR can help. Potential treatment challenges are addressed. A case example illustrates therapy for PTSD post-automobile accident. Research support for VRET for PTSD is summarized.

Ch 17: GAD, OCD, and Illness Anxiety Disorder 

Chapter 17 discusses virtual reality therapy (VRT) for generalized anxiety disorder (GAD), obsessive compulsive disorder (OCD), and illness anxiety disorder.  The chapter begins by exploring the triggers or factors that can predispose clients to develop these disorders, and the common sensations, fears, and fear-based actions frequently reported which create a vicious cycle of anxiety. The anxiety cycle model is described in detail in Chapter 2. Readers are introduced to a variety of VRT interventions, including but not limited to virtual reality exposure therapy (VRET), to reduce triggers, cope with sensations, counter fears, and change client actions associated with GAD, OCD, or illness anxiety disorder. For a more in-depth explanation of VRT and VRET in general, see Chapters 3 and 4. 

Examples include using virtual reality (VR) to provide exposure and response prevention (ERP) when treating OCD symptoms such as fear of germs and compulsive washing and cleaning, hyperreponsibility, compulsive checking, obsessional OCD, or compulsive ordering. Treatment challenges presented by the COVID-19 pandemic or by clients’ risk aversion are addressed. The chapter ends with a case example for each of the three disorders and a summary of the evidence base for using VR with these disorders.

Section IV: Other Issues 

Chapters 18 through 20 address more general issues in utilizing virtual reality (VR). Chapter 18 discusses how VR can be utilized in combination with a variety of theoretical and therapeutic approaches other than cognitive behavioral therapy (CBT). Chapter 19 answers frequently asked questions about clinical issues relating to virtual reality therapy (VRT). VR product questions, troubleshooting technical issues and practical considerations are also addressed. Chapter 20 looks toward the future, making predictions about likely changes in VR equipment, affordability, availability, virtual environments, and client demand for VRT. 

Ch 18: Virtual Reality and Non-CBT Therapies 

Virtual reality (VR) and virtual reality therapy (VRT) are compatible with multiple therapeutic approaches – not just with cognitive-behavioral therapy (CBT). Chapter 18 showcases how VR is a flexible, powerful, atheoretical tool that can be used by mental health professionals of various theoretical orientations. Examples illustrate how VR can be used with twelve treatment approaches: acceptance and commitment therapy (ACT), art and music therapy, dialectical behavior therapy (DBT), eye movement desensitization and reprocessing (EMDR), hypnosis and hypnotherapy, mindfulness and mindfulness-based therapies, narrative therapy, positive psychology interventions, psychodynamic therapy, relaxation therapy, schema therapy, and solution-focused therapy. A wide array of applications is presented, inspiring readers to explore how virtual experiences can be used to help clients in their own practices.  

Ch 19: Frequently Asked Questions

Therapists interested in starting to use virtual reality (VR) in psychotherapy will find answers to their most frequently asked questions in this chapter. Clinical questions answers questions commonly raised by therapists when first learning about VR therapy (VRT) and VR exposure therapy (VRET) including potential risks of VR, concerns that VR may harm the therapeutic alliance, where clinicians may get more training, etc. The section on VR product questions covers choosing a VR product, finding additional VR content, and evaluating consumer self-help VR apps (see also Appendix A VR Equipment and Content Types). 

Troubleshooting addresses issues like what to do if the lenses in the VR headset fog up, if the client cannot hear you, or the headset is not working. Practical questions include issues like whether VR is hard to learn and use, whether clients with glasses can wear VR headsets, pre-session preparation, how to charge and bill for VRT, etc. 

Ch 20: Future Directions 

Chapter 20 presents the author’s thoughts about the future of virtual reality (VR) and what therapists can expect looking forward. It discusses likely trends in VR equipment and in virtual reality therapy (VRT). Client demand for VRT is predicted to continue to increase. VR and VRT will continue to be the focus of media attention, in turn increasing consumer awareness and interest. VR products will continue to advance technologically, offering therapists more options and collecting more information about client response. VR equipment should become more widespread, more affordable, and more clinically useful and the quality and number of virtual scenarios will continue to increase. 

Appendix A: VR Equipment and Content Types

Appendix A provides background information for therapists on the types of equipment required for virtual reality (VR) therapy and different types of VR content used to create virtual environments. 

It provides an overview of the types of VR headsets and therapist workstations used with VR therapy products and discusses considerations for product/equipment selection, including requirements for Internet access and suitability for use with teletherapy. 

Three basic types of content used to create virtual environments include computer generated imagery (CGI), 3-dimensional videos, and 3-dimensional photos. CGI can also be used to modify videos and photos. The type of content used to create a virtual environment affects the client experience, therapist controls, and suitability for use in different aspects of therapy or with different clients. This appendix explains about different content types and the pros and cons of each type for various therapeutic applications. 

Appendix B: A Virtual Reality Therapy Checklist 

This appendix provides a checklist of therapist actions that can increase the likelihood of successful virtual reality therapy (VRT) for anxiety. Actions are presented chronologically, making it easy for therapists to recall and incorporate them during therapy. The checklist starts from the first contact with a potential client and includes actions to take before using virtual reality (VR) with a client, then moves through specific recommendations to follow during VRT. Suggestions specific to using VR for exposure are included for therapists who utilize virtual reality exposure therapy (VRET). These include ways therapists can prepare clients for successful exposure, monitor clients during exposure, and foster client progress. The checklist ends with actions for helping clients maintain treatment gains and prevent relapse.