Virtual Reality Therapy for Anxiety A Guide for Therapists,

1st Edition

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Contents

List of figures vii

Acknowledgments viii
About the Authors ix

1 Introduction 1

PART I
Anxiety Treatment Overview 9
2 Anxiety Cycle Model 11
3 Uses of VR in Anxiety Treatment 29
4 VR Exposure Therapy 37
5 VR Anxiety Treatment Protocol 55

PART II
Treating Fears and Phobias 87
6 Specific Phobias Overview 89
7 Blood-Injection-Injury Phobia 98
8 Claustrophobia 109
9 Driving Phobia 124
10 Flying Phobia 141
11 Height Phobia 154
12 Insect and Animal Phobias 167
vi Contents
PART III
Treating Other Anxiety Disorders 185
13 Panic Disorder and Agoraphobia 187
14 Social Anxiety Disorder 195
15 Stress, Tension, Insomnia 206
16 Posttraumatic Stress Disorder (PTSD) 214
17 GAD, OCD, and Illness Anxiety Disorder 223

PART IV
Other Issues 237
18 Virtual Reality and Non-CBT Therapies 239
19 Frequently Asked Questions 244
20 Future Directions 258

Epilogue 260
Appendix A: VR Equipment and Content Types 261
Appendix B: VR Reality Therapy Checklist 267
Index 270
Figures

1.1 VR Headset Example 4

1.2 VR Therapist Workstation Example 5
2.1 The Anxiety Cycle 13
2.2 Breaking the Anxiety Cycle 20
3.1 Relaxing Nature VE Example 30
7.1 BII Phobia VE Example 101
8.1 Claustrophobia VE Example 114
9.1 Driving VE Example 130
10.1 Flying VE Example 145
11.1 Height VE Example 158
12.1 Dog Phobia VE Example 169
13.1 Public Setting VE Example 191
14.1 Social Anxiety VE Example 195
14.2 Public Speaking VE Example 199
16.1 Combat PTSD VE Example 216
17.1 Washing Hands VE Example 226
A.1 CGI VE Example 264
A.2 3D Video VE Example 265
Acknowledgments

Many thanks to my collaborator, Debra Boeldt, PhD. I am sincerely grateful

to Walter Greenleaf, PhD, Mimi McFaul, PsyD, Matt Vogl, and the entire
National Mental Health Innovation Center team for their support for this
project from its inception. Thanks go to Kim Bullock, MD, Jessica Lake,
PhD, and Albert “Skip” Rizzo, PhD for reviewing the book proposal and
offering encouragement. In addition, thanks are due to Debra Boeldt, PhD,
Kim Bullock, MD, Chris Gilbert, PhD, and DeLee Lantz, PhD for assistance
with references and to Kim Bullock, MD, Tamara McClintock Greenberg,
PsyD, and Harry Nozicka, LCSW for feedback on the manuscript.
Thank you to the following companies, listed in alphabetical order, who
graciously gave permission to use images of their VR software to illustrate a
range of virtual environments: BehaVR, Inc. (Figures 7.1, 8.1, 14.1, and
Appendix A.2), C2Care (Figures 9.1, 10.1, and 11.1), Psious (Figures 3.1,
13.1, 17.1, and Appendix A.1), and Virtually Better, Inc. (Figures 12.1, 14.2,
and 16.1). Thanks also to Hands-On-Guide for permission to use diagrams of
the Anxiety Cycle (Figure 2.1) and Breaking the Anxiety Cycle (Figure 2.2).
Finally, and always, thanks to my husband for his editorial assistance and
steadfast loving support.
About the Authors

Elizabeth McMahon, PhD, is a clinical psychologist and recognized

expert in virtual reality therapy (VRT) for anxiety. She has specialized in
treating anxiety disorders for 40 years and has been using virtual reality
(VR) technology with clients since 2010.
She received her PhD in clinical psychology from Case Western
Reserve University and completed a predoctoral fellowship at the
University of Virginia Medical Center in Charlottesville, Virginia and a
postdoctoral residency at Sheppard-Pratt Psychiatric Hospital in
Towson, Maryland.
Before entering private practice, Dr. McMahon worked for Kaiser
Permanente Medical Group in Fremont, California, for over 30 years.
At Kaiser she specialized in anxiety disorders, helping create best
practice guidelines, teaching, and supervising postdoctoral psychology
residents.
Currently she trains therapists on anxiety treatment and using VR in
continuing education courses organized by ADAA, APA, CPA, PESI, VR
technology providers, and other organizations. For more information see
her website: www.elizabeth-mcmahon.com.
Her client workbook Overcoming Anxiety and Panic Interactive Guide
(2019) helps explain anxiety and its treatment and prepares clients to
benefit from VR therapy.
Special offer for therapists who treat anxiety: e-mail elizabeth@elizabeth-
mcmahon.com to receive a complimentary review copy of Overcoming
Anxiety and Panic Interactive Guide.
Debra Boeldt, PhD, is deputy director of the National Mental Health
Innovation Center at the University of Colorado Anschutz Medical
Campus. She received her PhD in clinical psychology from the University
of Colorado Boulder and completed an internship at the University of
California San Diego/Veterans Administration and a postdoctoral fellow-
ship at the Scripps Research Translational Institute.
Dr. Boeldt is an advocate of the adoption of VR to improve mental
health and behavioral health services. She has co-authored several peer-
x About the Authors
reviewed publications, is a frequent presenter at conferences, and supports
the Tech Innovation Network, a network of diverse clinical and commu-
nity partners that functions as a test bed through which new technological
solutions can be rapidly developed, iterated, tested, and validated.
1 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 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 nause-
ous. 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.”
DOI: 10.4324/9781003154068-1
2 Introduction
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.
 Introduction 3
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, claus-
trophobia, 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-com-
pulsive 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 sub-
clinical 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 treat-
ment. 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 ther-
apy, cognitive therapy, cognitive-behavioral therapy, dialectical behavior
therapy, ego state therapy, existential therapy, exposure therapy, eye move-
ment desensitization and reprocessing, family systems therapy, gestalt therapy,
guided imagery, hypnosis (directive and Ericksonian nondirective), mind-
fulness, motivational interviewing, positive psychology, psychodynamic ther-
apy, 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
4 Introduction
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 dif-
ferent 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

 Introduction 5
Clients may have a virtual body (avatar) within the VE. Have clients
physically mirror their avatar’s body position and movements. This dee-
pens 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 PTSD.
 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).

Figure 1.2 VR Therapist Workstation Example

6 Introduction
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.
 Introduction 7
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 tele-
therapy 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) (Gon-
çalves et al., 2012; Parsons & Rizzo, 2008; 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 Beha-
vior, 72, 371–380. doi: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. doi:10.1016/j.
janxdis.2018.08.003.
8 Introduction
Diemer, J., Lohkamp, N., Mühlberger, A., & Zwanzger, P. (2016). Fear and physiolo-
gical arousal during a virtual height challenge—effects in patients with acrophobia
and healthy controls. Journal of Anxiety Disorders, 37, 30–39. doi: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.
doi: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). doi: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. doi:10.1007/s13311-017-0534-y.
Parsons, T. D. & Rizzo, A. A. (2008). Affective outcomes of virtual reality exposure
therapy for anxiety and specific phobias: A meta-analysis. Journal of Behavior Ther-
apy and Experimental Psychiatry, 39(3), 250–261. doi: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. Journal of Anxiety Disorders, 22(3), 561–569.
doi: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. doi:10.3389/fpsyg.2019.01758.
Part I
Anxiety Treatment
Overview

This section explains the principles of virtual reality therapy (VRT) for
anxiety including:

 Anxiety cycle model explaining the causes of anxiety and how treat-
ment breaks this cycle. This anxiety model is not VR-specific and can
be used with a variety of diagnoses and approaches.
 Uses of virtual reality (VR) in anxiety treatment other than for exposure
therapy.
 Using VR for exposure therapy.
 An extended case example of a VR treatment protocol. See also the
Virtual Reality Therapy Checklist in Appendix B.

DOI: 10.4324/9781003154068-2