1. Using Virtual Reality Exposure Therapy in the Treatment of Phobia Amy Dunn, Gemma Hunt, Caroline Osborn and Phil Sequeira

2. Phobias Phobias are traditionally treated using exposure therapy or systematic desensitisation (Wolpe, 1958) Repeated exposure to phobic stimulus + relaxation techniques + components of CBT = gradually minimised phobic anxiety Phobias are irrational fears of non- threatening stimuli, involving physiological and cognitive stress BUT provision of exposure can present some serious challenges…

3. Controversies VR exposure therapy attempts to overcome these problems Safety issues - confronting fear in real situations (Newman and Adams, 2004) Ethical considerations/client confidentiality issues resulting from real- world context (Davidson and Smith, 2003)

4. VR Exposure Therapy VRET is not a new therapeutic system, but a tool for use in established methods e.g. systematic desensitisation and cognitive-behavioural therapies (CBTs) The use of VR in the treatment of phobia can offer increased control and containment of therapy (Klinger et al., 2005) Virtual reality exposure therapy (VRET) relates to the use of virtual environments (VEs) as a tool for the graded exposure to a phobic stimulus

5. Controversies in VRET Cyber-sickness –a kind of motion sickness induced by discrepancies between visual, vestibular and proprioceptive information (Robillard et al., 2003:468) Transferability of skills Effectiveness in inducing enough anxiety to treat phobias (Krijn et al., 2003) Cost Presence and immersion – The feeling of being in an environment even if one is not physically present (Robillard et al., 2003:468)

6. The Virtual Reality Suite This is achieved using three separate projected displays, which are blended together to create one seamless image The projectors and a rack containing all the image generators are located behind the screen in the projection room The VR theatre is designed to display large stereoscopic virtual imagery to a seated audience

17. Case Study Anxiety and Presence during VR Immersion: A Comparative Study of the Reactions of Phobic and Non- phobic Participants in Therapeutic Virtual Environments Derived From Computer Games (TVEDGs) Robillard, Bouchard, Fournier and Renaud (2003)

18. Aims and Rationale TVEDGS VEs created using standard computer games, which cost less than $50 and are compatible with PCs Can be modified by users with little computing experience Graphic quality is often superior Aims Do TVEDGs evoke appropriate phobic reaction? To assess the impact of simulator-sickness and sense of presence

19. Method Sample –13 phobic participants and 13 non-phobic participants, matched for age and gender –Phobias were arachnophobia, acrophobia and claustrophobia Procedure –5 minutes to familiarise with VE and equipment (HMD, tracker and game-pad) without phobic stimuli –20 minute session with phobic stimuli: both phobic and non-phobic participants experience the same phobic cues and are encouraged to interact with them –Verbal reports regarding anxiety, immersion and cyber- sickness given throughout and assessed by questionnaire at the end

20. The Virtual Environments Virtual environment for phobia of spiders - Version 2 (developed from Max Payne)

21. The Virtual Environments Virtual environment for phobia of heights - Version 2 (developed from Max Payne)

22. The Virtual Environments Virtual environment for claustrophobia - Version 1 (developed from Unreal Tournament )

23. Results Pre-exposure: Phobic participants had significantly higher levels of anxiety and a higher propensity to immerse During exposure: All participants except one reported low anxiety in neutral VEs Post-immersion: Phobic participants reported greater anxiety and sense of presence Phobic participants reported greater simulator sickness (though not significant)

24. Discussion Aim 1 – Can TVEDGs produce phobogenic stimuli? Results show that anxiety was the product of VE stimuli and not VR equipment Using TVEDGs, for a quarter of the cost of commercial VRTs, therapists can provide an equivalent level of treatment Aim 2 – What is the impact of simulator- sickness? Results suggest that simulator-sickness has no impact on phobogenic efficacy Adaptation effects – Regan, 1995

25. Discussion Aim 2 – What is the impact of presence? Anxiety was importantly related to sense of presence Group differences show that it was phobic participants who had a greater tendency to immerse Correlations and regressions show that anxiety and presence were the most highly correlated variables and most predictive of each other These findings support a synergistic relationship but the underlying reasons remain unclear

26. Conclusions of the Study Secondly, the findings demonstrate that high- costs, issues relating to immersion, and side- effects such as cyber-sickness, need not remain barriers to effectiveness in the use of VEs to treat phobia Firstly, phobogenic effectiveness of the inexpensive software used, shows that VR technology is now sufficiently advanced for VRET to move into the clinical mainstream

27. Remaining Issues Retrospective questionnaire Accuracy of recall Transferability of skills Standardised environments – Individual differences? Testing software efficacy/testing therapeutic efficacy Verbal reports Impact on immersion Demand characteristics

28. Thank you for listening Any Questions?

29. References Davidson, J., and Smith, M. (2003). Biophobias/technophilias: Virtual reality exposure as treatment for phobias of nature. Sociology of Health and Illness, 25(6), 644-661. King, N.J., Muris, P., and Ollendick, T.H. (2005). Childhood fears and phobias: Assessment and treatment. Child and Adolescent Mental Health, 10(2), 50-56. Klinger, E., Bouchard, S., Legeron, P., Roy, S., Lauer, F., Chemin, I., and Nugues, P. (2005). Virtual reality therapy Vs cognitive behaviour therapy for social phobia: A preliminary controlled study. Cyberpsychology and Behaviour, 8(1), 76- 88. Krijn, M., Emmelkamp, P.M.G., Biemond, R., de Wilde de Ligny, C., Shuemie, M.J., and van der Mast, C.A.P.G. (2003). Treatment of acrophobia in virtual reality: The role of immersion and presence. Behaviour Research and Therapy, 42, 229-239.

30. References Newman, C., and Adams, K. (2004). Dog gone good: Managing dog phobia in a teenage boy with a learning disability. British Journal of Learning Disabilities, 32, 35-38. Regan, E.C. (1995). Some evidence of adaptation to immersion in virtual reality. Displays, 16(3), 135-139. Robillard, G., Bouchard, S., Fournier, T., and Renaud, P. (2003). Anxiety and presence during VR immersion: A comparative study of the reactions of phobic and non- phobic participants in therapeutic virtual environments derived from computer games. Cyberpsychology and Behaviour, 6(5), 467-476. Virtual environments. Retrieved May 13 th 2005, from: http://www.uqo.ca/cyberpsy/index-en.html

31. References Davidson, J., and Smith, M. (2003). Biophobias/technophilias: Virtual reality exposure as treatment for phobias of nature. Sociology of Health and Illness, 25(6), 644-661. King, N.J., Muris, P., and Ollendick, T.H. (2005). Childhood fears and phobias: Assessment and treatment. Child and Adolescent Mental Health, 10(2), 50-56. Klinger, E., Bouchard, S., Legeron, P., Roy, S., Lauer, F., Chemin, I., and Nugues, P. (2005). Virtual reality therapy Vs cognitive behaviour therapy for social phobia: A preliminary controlled study. Cyberpsychology and Behaviour, 8(1), 76- 88. Krijn, M., Emmelkamp, P.M.G., Biemond, R., de Wilde de Ligny, C., Shuemie, M.J., and van der Mast, C.A.P.G. (2003). Treatment of acrophobia in virtual reality: The role of immersion and presence. Behaviour Research and Therapy, 42, 229-239.

32. References Newman, C., and Adams, K. (2004). Dog gone good: Managing dog phobia in a teenage boy with a learning disability. British Journal of Learning Disabilities, 32, 35-38. Regan, E.C. (1995). Some evidence of adaptation to immersion in virtual reality. Displays, 16(3), 135-139. Robillard, G., Bouchard, S., Fournier, T., and Renaud, P. (2003). Anxiety and presence during VR immersion: A comparative study of the reactions of phobic and non- phobic participants in therapeutic virtual environments derived from computer games. Cyberpsychology and Behaviour, 6(5), 467-476. Virtual environments. Retrieved May 13 th 2005, from: http://www.uqo.ca/cyberpsy/index-en.html

33. References Davidson, J., and Smith, M. (2003). Biophobias/technophilias: Virtual reality exposure as treatment for phobias of nature. Sociology of Health and Illness, 25(6), 644-661. King, N.J., Muris, P., and Ollendick, T.H. (2005). Childhood fears and phobias: Assessment and treatment. Child and Adolescent Mental Health, 10(2), 50-56. Klinger, E., Bouchard, S., Legeron, P., Roy, S., Lauer, F., Chemin, I., and Nugues, P. (2005). Virtual reality therapy Vs cognitive behaviour therapy for social phobia: A preliminary controlled study. Cyberpsychology and Behaviour, 8(1), 76- 88. Krijn, M., Emmelkamp, P.M.G., Biemond, R., de Wilde de Ligny, C., Shuemie, M.J., and van der Mast, C.A.P.G. (2003). Treatment of acrophobia in virtual reality: The role of immersion and presence. Behaviour Research and Therapy, 42, 229-239.

34. References Newman, C., and Adams, K. (2004). Dog gone good: Managing dog phobia in a teenage boy with a learning disability. British Journal of Learning Disabilities, 32, 35-38. Regan, E.C. (1995). Some evidence of adaptation to immersion in virtual reality. Displays, 16(3), 135-139. Robillard, G., Bouchard, S., Fournier, T., and Renaud, P. (2003). Anxiety and presence during VR immersion: A comparative study of the reactions of phobic and non- phobic participants in therapeutic virtual environments derived from computer games. Cyberpsychology and Behaviour, 6(5), 467-476. Virtual environments. Retrieved May 13 th 2005, from: http://www.uqo.ca/cyberpsy/index-en.html

35. References Davidson, J., and Smith, M. (2003). Biophobias/technophilias: Virtual reality exposure as treatment for phobias of nature. Sociology of Health and Illness, 25(6), 644-661. King, N.J., Muris, P., and Ollendick, T.H. (2005). Childhood fears and phobias: Assessment and treatment. Child and Adolescent Mental Health, 10(2), 50-56. Klinger, E., Bouchard, S., Legeron, P., Roy, S., Lauer, F., Chemin, I., and Nugues, P. (2005). Virtual reality therapy Vs cognitive behaviour therapy for social phobia: A preliminary controlled study. Cyberpsychology and Behaviour, 8(1), 76- 88. Krijn, M., Emmelkamp, P.M.G., Biemond, R., de Wilde de Ligny, C., Shuemie, M.J., and van der Mast, C.A.P.G. (2003). Treatment of acrophobia in virtual reality: The role of immersion and presence. Behaviour Research and Therapy, 42, 229-239.

36. References Newman, C., and Adams, K. (2004). Dog gone good: Managing dog phobia in a teenage boy with a learning disability. British Journal of Learning Disabilities, 32, 35-38. Regan, E.C. (1995). Some evidence of adaptation to immersion in virtual reality. Displays, 16(3), 135-139. Robillard, G., Bouchard, S., Fournier, T., and Renaud, P. (2003). Anxiety and presence during VR immersion: A comparative study of the reactions of phobic and non- phobic participants in therapeutic virtual environments derived from computer games. Cyberpsychology and Behaviour, 6(5), 467-476. Virtual environments. Retrieved May 13 th 2005, from: http://www.uqo.ca/cyberpsy/index-en.html

37. References Davidson, J., and Smith, M. (2003). Biophobias/technophilias: Virtual reality exposure as treatment for phobias of nature. Sociology of Health and Illness, 25(6), 644-661. King, N.J., Muris, P., and Ollendick, T.H. (2005). Childhood fears and phobias: Assessment and treatment. Child and Adolescent Mental Health, 10(2), 50-56. Klinger, E., Bouchard, S., Legeron, P., Roy, S., Lauer, F., Chemin, I., and Nugues, P. (2005). Virtual reality therapy Vs cognitive behaviour therapy for social phobia: A preliminary controlled study. Cyberpsychology and Behaviour, 8(1), 76- 88. Krijn, M., Emmelkamp, P.M.G., Biemond, R., de Wilde de Ligny, C., Shuemie, M.J., and van der Mast, C.A.P.G. (2003). Treatment of acrophobia in virtual reality: The role of immersion and presence. Behaviour Research and Therapy, 42, 229-239.

38. References Newman, C., and Adams, K. (2004). Dog gone good: Managing dog phobia in a teenage boy with a learning disability. British Journal of Learning Disabilities, 32, 35-38. Regan, E.C. (1995). Some evidence of adaptation to immersion in virtual reality. Displays, 16(3), 135-139. Robillard, G., Bouchard, S., Fournier, T., and Renaud, P. (2003). Anxiety and presence during VR immersion: A comparative study of the reactions of phobic and non- phobic participants in therapeutic virtual environments derived from computer games. Cyberpsychology and Behaviour, 6(5), 467-476. Virtual environments. Retrieved May 13 th 2005, from: http://www.uqo.ca/cyberpsy/index-en.html

39. References Davidson, J., and Smith, M. (2003). Biophobias/technophilias: Virtual reality exposure as treatment for phobias of nature. Sociology of Health and Illness, 25(6), 644-661. King, N.J., Muris, P., and Ollendick, T.H. (2005). Childhood fears and phobias: Assessment and treatment. Child and Adolescent Mental Health, 10(2), 50-56. Klinger, E., Bouchard, S., Legeron, P., Roy, S., Lauer, F., Chemin, I., and Nugues, P. (2005). Virtual reality therapy Vs cognitive behaviour therapy for social phobia: A preliminary controlled study. Cyberpsychology and Behaviour, 8(1), 76- 88. Krijn, M., Emmelkamp, P.M.G., Biemond, R., de Wilde de Ligny, C., Shuemie, M.J., and van der Mast, C.A.P.G. (2003). Treatment of acrophobia in virtual reality: The role of immersion and presence. Behaviour Research and Therapy, 42, 229-239.

40. References Newman, C., and Adams, K. (2004). Dog gone good: Managing dog phobia in a teenage boy with a learning disability. British Journal of Learning Disabilities, 32, 35-38. Regan, E.C. (1995). Some evidence of adaptation to immersion in virtual reality. Displays, 16(3), 135-139. Robillard, G., Bouchard, S., Fournier, T., and Renaud, P. (2003). Anxiety and presence during VR immersion: A comparative study of the reactions of phobic and non- phobic participants in therapeutic virtual environments derived from computer games. Cyberpsychology and Behaviour, 6(5), 467-476. Virtual environments. Retrieved May 13 th 2005, from: http://www.uqo.ca/cyberpsy/index-en.html