Specific phobia can be treated successfully with exposure therapy. Although exposure therapy has strong effects on self-reported ratings and behavioral avoidance, effects on measures derived from electroencephalography (EEG) are scant and unclear. To fill this gap, spider-phobic individuals received either in-vivo or virtual reality exposure treatment. Patients were tested twice (one week before and after treatment), and control subjects once. In each session, EEG was recorded to spider pictures as well as other positive, negative, and neutral pictures. During EEG recording, participants performed a simple detection task while task-irrelevant pictures were shown in the background. The task was used to reduce potential confounding effects from shifts of attention. After the task, subjects were shown the pictures again and rated each in terms of their emotional reaction (arousal and pleasantness). The results showed that before treatment, patients rated spiders as more negative than did control subjects. Patients also showed elevated early posterior negativity (EPN) and late positive potential (LPP) to spiders. After treatment, the negative emotional ratings of spiders were substantially reduced. Critically, Bayesian analyses suggested that EPN and LPP were unaffected by treatment and that the treatment groups did not differ in their responses (EPN, LPP, and ratings). These findings suggest that the effects of in vivo and virtual reality exposure therapy are similar and that the initial stages of motivated attention (EPN and LPP) are unaffected by treatment.

Consumer Virtual Reality (VR) technology offers a powerful, immersive medium for scalable dissemination of mental health interventions. Decades of research has shown VR exposure therapy to be efficacious in the treatment of anxiety disorders and that the fear reduction generalizes to real-world stimuli. Many studies also report continued improvement over time, after discontinuing VR use. The lowered threshold hypothesis states that this continued improvement is moderated by lowering the threshold to conduct subsequent in-vivo exposure. The current study is the first to formally test this hypothesis, using data from a recent trial on automated VR exposure therapy for spider phobia, in which participants (n = 49) were followed for 1 year, completing assessments 1 week, 3 and 12 months post-treatment. The assessment included validated self-report of phobia symptoms, a standardized behavioral approach test featuring a real spider, and a questionnaire for self-reporting frequency of in-vivo exposures since last assessment. Number of in-vivo exposures was found to be independently associated with greater symptom decrease in longitudinal outcome models. In sequential structural equation models, immediate post-treatment symptom reduction was associated with subsequent in-vivo exposures, which in turn was associated with continued symptom reduction. However, this applied only to self-reported phobia symptoms (not behavioral avoidance) and no associations were found past 3 months. Our findings offer preliminary, partial support for the lowered threshold hypothesis, suggesting that VR exposure interventions may benefit from including explicit in-virtuo to in-vivotransitioning components.

Virtual Reality (VR) can be used as a therapeutic tool to conduct efficacious in-session exposure therapy by presenting virtual equivalents of phobic stimuli, yet past hardware restrictions hindered implementation in routine care and effectiveness studies. The current study examines the effectiveness of a VR-assisted treatment protocol for public speaking anxiety with demonstrated efficacy, this time in routine care, using affordable VR hardware. Participants (n = 23) were recruited via a private clinic and treated by one of four psychologists with only minimal VR-training. Using a single-subject design and dual-slope modeling (adjusting the treatment-onset slope for treatment effects), we found a significant, large decrease in self-rated public speaking anxiety following the primary three-hour session, similar in magnitude to the previous efficacy trial. Multilevel modeling of in-session process measures suggests that the protocol works as intended, by decreasing catastrophic belief expectancy and distress, and increasing perceived performance quality. Adherence to the online transition program that followed-encouraging in-vivo exposure-was relatively poor, yet symptoms decrease continued. No change was observed over the three-month follow-up period. We conclude that VR exposure therapy can be effective under routine care conditions and is an attractive approach for future, large-scale implementation and effectiveness trials.

The advent of affordable Virtual Reality (VR) technology has spurred consumer and commercial interest in VR relaxation applications, which has quickly grown into a popular non-gaming genre on digital marketplaces. While laboratory studies have demonstrated efficacy of VR relaxation for mental health purposes, little is known about how users experience this type of intervention and no study has examined the reception of consumer versions among regular users in everyday life. Studying published user reviews offers a unique window into naturalistic user experiences that complements traditional qualitative methods by circumventing the sampling bias of interview studies, and allowing analyses on full samples, unconstrained by coding resources. Using an innovative, semi-automated Natural Language Processing technique, the current study analyzed 1379 published reviews (including star ratings) of 30 different VR relaxation applications available for the Oculus Go and Gear VR. The uncovered topic structure and sentiment analysis thereof suggests that users have an overall positive view of VR relaxation applications, describing them as successful in inducing immersion and relaxation, and having appreciated gamification elements. However, perceived quality varied substantially between applications that explained more variance in star ratings than specific features. Critical issues raised were both technical (e.g. “overheating”) in nature and related to specific design elements and use. Implications for the design of consumer VR applications and future research are discussed.

Background: Virtual reality exposure therapy is an efficacious treatment of anxiety disorders, and recent research suggests that such treatments can be automated, relying on gamification elements instead of a real-life therapist directing treatment. Such automated, gamified treatments could be disseminated without restrictions, helping to close the treatment gap for anxiety disorders. Despite initial findings suggesting high efficacy, very is little is known about how users experience this type of intervention.

Objective: The aim of this study was to examine user experiences of automated, gamified virtual reality exposure therapy using in-depth qualitative methods.

Methods: Seven participants were recruited from a parallel clinical trial comparing automated, gamified virtual reality exposure therapy for spider phobia against an in vivo exposure equivalent. Participants received the same virtual reality treatment as in the trial and completed a semistructured interview afterward. The transcribed material was analyzed using thematic analysis.

Results: Many of the uncovered themes pertained directly or indirectly to a sense of presence in the virtual environment, both positive and negative. The automated format was perceived as natural and the gamification elements appear to have been successful in framing the experience not as psychotherapy devoid of a therapist but rather as a serious game with a psychotherapeutic goal.

Conclusions: Automated, gamified virtual reality exposure therapy appears to be an appealing treatment modality and to work by the intended mechanisms. Findings from the current study may guide the next generation of interventions and inform dissemination efforts and future qualitative research into user experiences.

Background: Virtual Reality exposure therapy (VRET) is an evidence-based treatment of phobias and recent research suggests that this applies also to self-contained, automated interventions requiring no therapist guidance. With the advent and growing adoption of consumer VR technology, automated VR intervention have the potential to close the considerable treatment gap for specific phobias through dissemination as consumer applications, self-help at clinics, or as blended treatment. There is however a lack of translational effectiveness studies on VRET treatment effects under real-world conditions.

Methods: We conducted a single-arm (n = 25), single-subject study of automated, gamified VRET for fear of spiders, under simulated real-world conditions. After setup and reading instructions, participants completed the automated, single-session treatment by themselves. Self-rated fear of spiders and quality of life served as outcome measures, measured twice before, and one and two weeks after treatment, and at a six-month follow-up. Session characteristics and user experience measures were collected at the end of the session.

Results: Mixed-effects modeling revealed a significant and large (d = 1.26) effect of treatment-onset on phobia symptoms (p < .001), and a small (d = 0.49) effect on quality of life (p = .025). Results were maintained at a six-month follow-up (p > .053). The intervention was tolerable and practical. There were no significant correlations between any user experience measure and decrease in phobia symptoms (p > .209).

Conclusions: An automated VRET intervention for fear of spiders showed equivalent effects on phobia symptoms under effectiveness conditions as previously reported under efficacy conditions. These results suggest that automated VRET applications are promising self-help treatments also when provided under real-world conditions.

Background: Automated virtual reality exposure therapies (VRETs) are self-help treatments conducted by oneself and supported by a virtual therapist embodied visually and/or with audio feedback. This simulates many of the nonspecific relational elements and common factors present in face-to-face therapy and may be a means of improving adherence to and efficacy of self-guided treatments. However, little is known about alliance toward the virtual therapist, despite alliance being an important predictor of treatment outcome.

Objective: In this study, we aimed to evaluate the first alliance instrument developed for use with embodied virtual therapists in an automated treatment format—the Virtual Therapist Alliance Scale (VTAS)—by (1) assessing its psychometric properties, (2) verifying the dimensionality of the scale, and (3) determining the predictive ability of the scale with treatment outcome.

Methods: A psychometric evaluation and exploratory factor analysis of the VTAS was conducted using data from two samples of spider-fearful patients treated with VRET and the help of an embodied, voice-based virtual therapist (n=70). Multiple regression models and bivariate correlations were used to assess the VTAS relationship with treatment outcome, according to self-reported fear and convergence with presence and user-friendliness process measures.

Results: The VTAS showed a sound two-factor solution composed of a primary factor covering task, goal, and copresence; adequate internal consistency; and good convergent validity, including moderate correlation (r=.310, P=.01) with outcomes over follow-up.

Conclusions: These preliminary results suggest that alliance toward a virtual therapist is a significant predictor of treatment outcome, favors the importance of a task-goal over bond-factor, and should be explored in studies with larger sample sizes and in additional forms of embodiment.

Exposure therapy for specific phobia involving systematic and repeated presentation of an aversive stimuli or situation is a highly effective treatment for reducing fear and anxiety. Dissemination of this evidence-based treatment has proved challenging, however, and for over 20 years an alternative method of delivery using virtual reality technology has been explored with positive results. This thesis consists of three empirical studies examining a new generation of virtual reality exposure therapy (VRET) that by using automation, inexpensive hardware, and downloadable software aims to ensure that a highly efficacious exposure therapy can be made available to almost anyone. Study I evaluated the efficacy of this novel automated VRET for spider phobia as compared to gold-standard in-vivo one-session treatment (OST) using a randomized non-inferiority design. Results indicated that large effect size reductions in self-reported fear were evident at post-assessment in both treatments and the automated VRET was not inferior to OST at 3- and 12-months follow-up according to behavioral approach test, but was significantly worse until 12-month follow-up. No significant difference was noted on a questionnaire measuring negative effects of treatment. Study II conducted a process measure evaluation of patient alliance towards the virtual therapist used in the VRET treatment with a purpose-built questionnaire entitled the Virtual Therapist Alliance Scale (VTAS). Exploratory factor analysis indicated a sound two-factor solution composed of a primary task, goal and co-presence factor and a secondary bond and empathy factor. Psychometric evaluation of the VTAS suggested good internal consistency, and a moderate correlation between the VTAS and change in self-reported fear over follow-up. Study III assessed what individuals with a fear of spiders found most frightening about spiders. Both quantitative ratings and qualitative descriptions indicated that movement characteristics were reported as most fear provoking and to a lesser extent appearance characteristics, however factor analysis of scores in these categories did not find a correlation with participant baseline self-reported fear. Overall, the above findings suggest that VRET is a potential alternative to OST for the treatment of spider phobia also with respect to therapist alliance, and spider movement characteristics should be emphasized in future VRET treatments.

Virtual reality exposure therapy (VRET) is an efficacious treatment for fear and anxiety and has the potential to solve both logistic issues for therapists and be used for scalable self-help interventions. However, VRET has yet to see large-scale implementation in clinical settings or as a consumer product, and past research suggests that while therapists may acknowledge the many advantages of VRET, they view the technology as technically inaccessible and expensive. We reasoned that after the 2016 release of several consumer virtual reality (VR) platforms and associated public acquaintance with VR, therapists' concerns about VRET may have evolved. The present study surveyed attitudes toward and familiarity with VR and VRET among practicing cognitive behavior therapists (n = 185) attending a conference. Results showed that therapists had an overall positive attitude toward VRET (pros rated higher than cons) and viewed VR as applicable to conditions other than anxiety. Unlike in earlier research, high financial costs and technical difficulties were no longer top-rated negative aspects. Average negative attitude was a larger negative predictor of self-rated likelihood of future use than positive attitude was a positive predictor and partially mediated the positive association between VRET knowledge and likelihood of future use, suggesting that promotional efforts should focus on addressing concerns. We conclude that therapist's attitudes toward VRET appear to have evolved in recent years, and no longer appear to constitute a major barrier to implementing the next generation of VR technology in regular clinical practice.