Virtual Reality Exposure Therapy: How It Works & Who It’s Right For

What Is Exposure Therapy?

Exposure therapy is a form of cognitive behavioral therapy (CBT) that was created to help confront and reduce people’s reactions to fears and difficult situations. Many people avoid situations that make them feel anxious or fearful, which can become a concern if their avoidance is keeping them from important life tasks or events they would like to attend.¹¹ The goal of exposure therapy is to address, process, and eventually confront these fears to reduce the potentially severe limitations on a person’s life.¹¹

Exposure therapy is considered an evidence-based treatment for phobias, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder, and other anxiety disorders.¹¹ A number of techniques are used in exposure therapy that guide the person towards slowly increasing their ability to cope with these difficult fears and situations. There are a variety of ways to approach exposure therapy, but as technology advances, virtual reality exposure therapy is becoming more popular.

What Is Virtual Reality Exposure Therapy?

Virtual reality exposure therapy is a computerized form of exposure therapy, providing exposure to virtual stimuli in a controlled setting.^1,3 Virtual Reality Exposure Therapy is a technology-enabled treatment approach that integrates computer graphics and body-tracking devices. During a virtual reality exposure session, states of arousal can be tracked by monitoring physiological indicators of stress such as heart rate and respiration through the use of biofeedback equipment.

After this desensitization to a virtual environment, the individual may feel more equipped to take the next step and engage in real life (i.e., in vivo) exposure to the feared object or situation. Virtual Reality Exposure Therapy allows for the integration of evidenced based interventions, supported and backed by research for positive mental health wellness outcomes such as cognitive behavioral therapy and mindfulness based approaches.

Benefits of Virtual Reality Therapy

There are several benefits to engaging in Virtual Reality Exposure Therapy, which include the ability to view an artificial environment as opposed to imagining or waiting for real life exposure to adverse stimuli, allowing faster access to practicing coping skills. Additionally, virtual environments are customizable and can be tailored to suit unique needs of the individual.

This allows for more flexibility in adjusting exposure to target stimuli at any time. Virtual reality can be viewed as a bridge between a virtual stressful environment and the real world.

What Equipment Is Typically Used for Virtual Reality Therapy?

In order to engage in Virtual Reality Exposure Therapy, a provider uses programmed computers, immersion devices and artificially created environments that mirror reality through a simulated experience. The individual engaging in Virtual Reality Exposure Therapy is equipped with goggles that allow them access into the virtual environment. Modernized virtual reality equipment has been adapted for use with smartphones allowing for use of gyroscopes and motion sensors to track head, body, and hand positions while also monitoring subjective units of distress.

In addition to the simulated environment that individuals access, Virtual Reality Exposure Therapy also allows for the measurement of heart rate variability with biofeedback devices designed to track physiological changes within the body such as heart rate and skin activity.

Heart rate variability simply refers to changes in heart rate and skin activity. The equipment used in a Virtual Reality Exposure Therapy session is typically provided by the therapist, but some individuals receiving this treatment approach are able to purchase their own headsets or goggles either through their therapist or online, with prices ranging from under $50.00 to as high as a couple hundred dollars.

What Can Virtual Reality Therapy Help With?

Virtual Reality Exposure Therapy is ideal for a wide range of populations and age groups. In addition to use among adults, children and teens looking for innovative ways to learn healthy coping skills can be ideal candidates for Virtual Reality Exposure Therapy. Research to examine the use of Virtual Reality Exposure Therapy among adolescents ranging in age from 13 to 16 who were struggling with fear of public speaking due to social anxiety found that use of Virtual Reality Exposure Therapy was effective in helping adolescents overcome symptoms of social anxiety such as fear of public speaking.⁴

Virtual Reality Exposure Therapy is a popular treatment modality, yet it is highly underutilized and less likely to be offered as a treatment approach.² Trained therapists and mental health professionals would be most equipped to provide this treatment approach to clients dealing with a range of mental health concerns such as anxiety and traumatic stress conditions. While there is training available for the use of Virtual Reality Exposure Therapy, it is sparse and few mental health providers are trained in this therapeutic approach.

Virtual Reality Exposure Therapy for PTSD

Virtual reality has been used extensively in the delivery of prolonged exposure for Post Traumatic Stress Disorder (PTSD) among military personnel.⁵ Military funding has allowed for several studies examining the efficacy of this approach. With Virtual Reality Exposure Therapy, providers are able to utilize a 360-degree, interactive computer simulated environment.

In a meta-analysis comparing 14 Virtual Reality Exposure Therapy studies with military populations experiencing PTSD, researchers found Virtual Reality Exposure Therapy to be a highly effective treatment approach.⁶

Virtual Reality Exposure Therapy has also been used in the treatment of PTSD among military personnel with Virtual Iraq.⁶ This approach utilized a head mounted display and a game pad, in which soldiers are tasked to travel through a simulated Iraq environment while in a Humvee. Through this systematic exposure to the feared stimuli and/or environment, the intent is to reduce symptoms of anxiety and traumatic stress. Outcomes among the first group of individuals to receive this treatment found that PTSD symptoms significantly decreased, where 75% of individuals no longer met the DSM-V criteria for the diagnosis. Another study utilizing the Virtual Iraq setup found that symptoms of PTSD reduced by approximately fifty percent of veterans diagnosed with PTSD.¹

Virtual Reality Exposure Therapy for Anxiety Disorders

Virtual Reality Exposure Therapy is a practical treatment for anxiety disorders and its effectiveness is supported by empirical research with a strong evidence base.^1,2,5 Specifically, these research studies support the use of Virtual Reality Exposure Therapy in the treatment of anxiety and phobia symptoms. This computerized treatment approach allows clients to manage symptoms of anxiety through gradual or repeated exposure to feared stimuli.

The end goal is to change thought patterns, behaviors and responses that disrupt daily functioning. Feared stimuli can vary from person to person but can range from living organisms, inanimate objects, situations, activities, thoughts, mental images, physical symptoms, or experiences. Exposure to feared stimuli allows for extinction (i.e., weakening of a learned response) of the feared response, which is a plus in comparison to other forms of exposure therapy (i.e., such as in vivo exposure), which do not allow for exposure to the cues that are most feared.

Virtual Reality Exposure Therapy for Specific Phobias

In addition to the treatment of trauma and stressor related conditions such as PTSD, Virtual Reality Exposure Therapy is a popular treatment for anxiety disorders such as specific phobias, like an extreme fear of an animal. The virtual environment can be simulated to include feared animals or insects such as spiders, snakes or roaches.

Virtual Reality Exposure Therapy has recently been adapted for the treatment of fear of public speaking, fear of heights, addiction, bullying, claustrophobia, depression and eating disorders. In addition to common uses, virtual reality is also being utilized in the treatment of sleep-wake disorders, sport performance, stress and test anxiety.

Why Does Virtual Reality Exposure Therapy Work?

Virtual reality includes visual and, often, physical displays to help create digitally-based sensory responses akin to the real world. By combining VR and these different approaches, VRET provides the ability to be exposed to and gain feedback in a safe situation that allows someone to work on, process, and weaken the connections and responses formed. In addition, VRET provides the ability to work up to a fear that may be higher on the list and is not as accessible. Ultimately, VRET allows for a digital and safe exposure experience that allows people to challenge their reactions, process the stimuli, and reduce these symptoms as well as, hopefully, become able to do more and engage in more things in real life.¹³

The theories of habituation, extinction, emotional processing, and self-efficacy each play a role in exposure, especially as a combination. All theories or one alone may be used to explain the effectiveness of virtual reality exposure therapy:

• Habituation theory is applied by being repeatedly exposed to a stimulus (e.g. someone who was previously attacked in a park and now avoids parks using VR to be exposed to a virtual “park” setting) to decrease anxiety and increase familiarity.
• Extinction theory is applied by trying to reduce the conditioned response (e.g. fear, avoidance, anxiety) by weakening the reinforcement of an unconditioned stimulus (being attacked while at the park); this connection is weakened by being repeatedly exposed to a conditioned stimulus (the park) without the unconditioned stimulus.
• Emotional processing is applied by being repeatedly exposed to a stimulus (the park) to challenge the response (panic, anxiety) and unhealthy meaning (e.g. “I’m too weak to defend myself, I’m an idiot for not expecting that.”) that was initially stored in one’s memory.
• Self-efficacy is applied by learning techniques to cope with or master a situation or fear that influences a fear or anxiety response; by learning these, one identifies and recognizes their ability to handle a fearful situation and can apply it with similar stimuli.¹²

What to Expect at Your First Session

Before starting Virtual Reality Exposure Therapy, there will be an initial consultation provided by the therapist to determine if a prospective client is a good fit for Virtual Reality Exposure Therapy prior to starting. Once an individual is deemed eligible to use Virtual Reality Exposure Therapy, during the first session, the therapist will provide a biopsychosocial assessment, allowing them to learn as much about their client and their goals for therapy prior to jumping into the treatment process.

Once this is completed, the next step would be treatment planning, providing basic education about Virtual Reality Exposure Therapy, expectations and offering an opportunity for the client to ask questions or express concerns. It is important to keep in mind that each therapists’ operating procedures will vary, but would include many of the standard processes mentioned. Subsequently, the treatment process will begin and can be done in person as well as virtually.

What Is a Typical VRET Session like?

During the exposure therapy session, where the therapist may be treating a specific phobia or trauma and stressor related condition, the client will experience exposure to fearful stimuli or a feared environment. Through utilization of VR equipment such as the headset or goggles, the client will gain direct access to the simulated or artificial environment, while building up the intensity of their exposure to the stimuli.

Due to the flexibility in controlling the simulated environment, the individual receiving the treatment should be aware that the therapist is able to reduce or remove exposure to the fear at any time. Through use of biofeedback equipment, bodily sensations can be measured and tracked with sensors in between treatments. If the Virtual Reality Exposure Therapy session is taking place virtually, all that is needed is the headset or goggles and access to a smart phone as the virtual environment is accessed through an app on the individual’s phone and controlled by the provider.

VRET Examples

VRET for a Phobia

Dan, a 31-year old male, recently bought a house and realized shortly after that it was infested with spiders. Dan has an intense phobia of spiders, often leading to panic attacks. He moved in with his parents after scheduling to get the house treated, but has struggled to return and even see how the house looks because of his fear and panic surrounding the spiders.

Dan meets with a VRET therapist to process this, as he would prefer to return to his new home. He and his therapist began with an exposure hierarchy, initially listing these fears to assess for comfort. He and the therapist settle on habituation and self-efficacy approaches.

In each session, he wears VR goggles and biofeedback sensors, due to his panic attacks, and watches virtual spiders pass near him. He does this for a longer time each session as his therapist monitors his sensors. After each exposure, they process the feelings brought up, engage in education and practice coping techniques, and, sometimes try again. Eventually, Dan begins to visit his home and, ultimately, after 2 months, is able to move back in with continued therapy.

VRET for PTSD

Jane, a 29-year-old female, recently returned from her third year-long deployment in an active combat zone. Although she adjusted well on her first return, she recently began experiencing symptoms of post-traumatic stress disorder (PTSD). During debriefing, she talked frequently of her symptoms and continues, 6 months later, to deal with flashbacks, hypervigilance, nightmares, snapping at people, and having difficulties at work and with her family as a result.

Jane met with a VRET therapist with military knowledge to begin trying to reduce some of these symptoms with a request to get her life back. Loud noises were a significant trigger for her, often leading to what others perceived as exaggerated responses. Jane and her therapist began to enact Virtual Iraq VRET, with a head mount display and game pad, at the beginning of each session over increased time while noting specific triggers and using coping techniques and other skills to adjust as she experienced them.⁶

After some time, Jane was able to return to work and had a plan of action with her employers and family for handling loud noises and particularly intrusive flashbacks.

VRET for Social Anxiety

Taylor, who is 19 years old, was often considered shy in high school. However, Taylor often had difficulty in crowds, never tried to gain attention by engaging in talent shows or groups requiring a lot of social interaction, and often struggled with social interaction. Taylor’s school counselor suggested they may have social anxiety disorder (SAD), but did not actually help them get treatment.

After a year of college, Taylor is experiencing many of the same issues and is having trouble finding community, but wants to find friends and connection while in school. Taylor’s therapist diagnosed him with social anxiety after a thorough assessment and suggested the use of VRET. In the session, Taylor’s therapist had them engage with others and practice contact with multiple people over increasing time, with a headset and biofeedback sensors. Taylor was also challenged to find or challenge negative thoughts like “I’m an idiot,” if they occurred while Taylor was interacting both in real life and on VR.

After some time, Taylor has made a small group of local friends as well as some friends online and is engaging more frequently in classes.

What Are the Barriers to Getting Virtual Reality Therapy?

While there is a plethora of research supporting Virtual Reality Exposure Therapy and many benefits to its use in clinical practice, there are several barriers to Virtual Reality Exposure Therapy affecting both providers and clients. Even when appropriately diagnosed and referred to a clinician providing the service, Virtual Reality Exposure Therapy continues to be underutilized due to the client’s fear of exposure.⁷ Those who start the treatment may prematurely drop out or discontinue the treatment if it involves prolonged exposure to fearful cues.

Another barrier is the limited availability of trained clinicians to provide the treatment. Not many clinicians utilize Virtual Reality Exposure Therapy, making it harder for anyone interested in this approach to find a provider. In addition to this, many clinicians are skeptical and have negative beliefs about the efficacy of the treatment.

However, research found that when clinicians attended a full day intensive training on Virtual Reality Exposure Therapy, negative beliefs about the treatment approach decreased significantly.⁷ Since not many clinicians provide Virtual Reality Exposure Therapy, there are no published price points at this time. For someone considering Virtual Reality Exposure Therapy, it would be best to inquire about pricing and insurance coverage directly with a clinician.

Additional barriers to use of Virtual Reality Exposure Therapy are limitations in available virtual environments.² This makes it harder to customize simulated environments to be specific to each individual. Another factor to keep in mind is that use of the equipment for prolonged periods can result in nausea or discomfort.

Keeping safety in mind, it is not recommended to be immersed in the virtual environment for too long as individuals may become disoriented, dizzy and their vision may become blurred. Virtual Reality Exposure Therapy equipment can trigger headaches, migraines or seizures among those who suffer from these conditions. Individuals with schizophrenia and related conditions should not utilize this equipment as the virtual environment can increase symptoms of delusions.

Finding a Therapist Who Provides Virtual Reality Exposure Therapy

It can be difficult to acknowledge the need for this sort of therapy, but a VRET therapist may be able to help you to challenge these fears and help you decrease avoidance. You can inquire with your primary care physician or another specialist if they know of anyone in your area that provides VRET. There are also a number of online directories where you can search for therapists meeting your insurance requirements and mental health needs, while searching specifically for someone who offers VRET.

Who Is Eligible to Provide VRET?

There is training that equips a provider with the essential skills needed for providing Virtual Reality Exposure Therapy. However, there are no known certifications required to provide this treatment. Any mental health provider who is interested in this approach can take training through organizations such as Psious. Psious is one of the leading organizations providing VR equipment that is specifically designed for the treatment of a range of mental health conditions.

Questions to Ask Before Starting Virtual Reality Exposure Therapy

Some key questions to ask a therapist before starting virtual reality exposure therapy include:

• What are the benefits to engaging in this treatment?
• What are the disadvantages to engaging in this treatment?
• Are there any side effects of engaging in Virtual Reality Exposure Therapy?
• How long will Virtual Reality Exposure Therapy last before symptom improvement?
• How long will the treatment outcomes last?
• Do you accept insurance for Virtual Reality Exposure Therapy? If not, what is the cost for the treatment?
• Are there any safety concerns to consider?
• What can I expect from a Virtual Reality Exposure Therapy session?
• What are alternative options to Virtual Reality Exposure Therapy?

How Effective Is VR Therapy?

While there is not a great amount of data yet, VRET has become more adaptable and studied within the last 20 years, especially due to the increase in access to virtual reality gear:

• Quite a few studies have noted the influence of exposure-based therapy with a significant reduction in avoidance, impairment, and over 50% of the test samples no longer met the criteria for a phobia.¹²
• Other researchers have observed a significant reduction of symptoms in their own samples and in literature view of other studies on VRET in treating panic and anxiety disorders.^15,16
• Another study observed a significant reduction in symptoms surrounding fear of catching COVID-19 through VRET.¹⁴

Limitations & Concerns

Although continued development and research is being done, VRET does have its limitations. VRET does not require a specific certification and although training does exist, it is not readily available or accessible.¹⁵ While VRET has been observed to be helpful, there is limited VRET education available on a regular basis for mental health professionals. It has also been noted that inclusion criteria for research tends have been restrictive which has made it difficult to get statistics in diverse samples and treatment settings.¹⁵ In addition, research indicated that clients may be impaired by a digital type of motion sickness in VRET.¹⁶

History of Virtual Reality Therapy

Virtual reality was a term coined in 1989 by Jaron Lanier, which influenced its presence in the field of psychiatric treatment in the 1990’s and early 2000’s.⁸ Virtual reality (VR) started more than 50 years ago using a stereo head-mounted display, head tracking and computer graphics to access it.

In the 1980s and 1990s, VR re-emerged through use of cathode ray tube (CRT) displays. Since then, there has been an abundance of research to assess its efficacy in many fields including but not limited to medicine, business, psychotherapy and sports. Virtual reality is considered a form of prolonged exposure therapy as a treatment for anxiety disorders. Today, the efficacy of Virtual Reality Exposure Therapy in treating other psychological conditions such as depression continues to be explored.¹

Final Thoughts on VRET

Virtual Reality Exposure Therapy offers a wide range of advantages compared to traditional exposure therapy techniques such as in vivo exposure therapy. Since its inception in the field of behavioral health, the increase in familiarity of Virtual Reality Exposure Therapy has made it an appropriate tool for mirroring reality. As more clinicians trust the technology, there is a greater opportunity to examine treatment efficacy.

VR is an expensive technology, but there is data stating that the price of providing the service is declining and the equipment is becoming more accessible to clinicians. Either way, the benefits of Virtual Reality Exposure Therapy are worth the cost.