Virtual Reality Therapy for Anxiety

A Guide for Therapists

Elizabeth McMahon, Debra Boeldt

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000473803
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychopathologie

Practical, down to earth, clearly written, and easy for therapists to understand and apply, Virtual Reality Therapy for Anxiety is a useful guide for any clinician treating anxiety, regardless of setting (in-office or via telehealth), theoretical orientation, or level of training. Written by an experienced psychologist who has used multiple VR systems since 2010, it's the only up to date, clinically informed, evidence-based training manual available.

Easy-to-understand concepts and diagrams explain anxiety and its treatment, and the book incorporates research findings and clinical expertise. VRT is described step by step with multiple case examples, and an extended case-vignette chapter presents a session-by-session treatment protocol of a complex case with transcript excerpts. Key findings and quotations from research are also presented.

After completing the guide, therapists and other mental health professionals will understand the unique clinical benefits of VR, be prepared to use VR in therapy comfortably and effectively either in the office or remotely, and will have expertise in a new, needed, and empirically validated treatment for a common clinical problem.

1 Introduction

DOI: 10.4324/9781003154068-1

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 months 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 and 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, posttraumatic stress disorder (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 three-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.

Figure 1.1 VR Headset Example

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 inte...