Abstract

Research demonstrating the effectiveness of virtual reality in the treatment of clinical disorders has increased over the last decade. The usability and affordability has made the technology within reach of clinicians. Counselors will soon have the opportunity to incorporate virtual reality in their treatment. The intent of this paper was to review the outcome studies regarding the effectiveness of virtual reality in the treatment of specific phobias. It was found that the use of virtual reality offers many potential benefits to the treatment process. However, due to the research available containing a majority of case studies, small sample sizes, and population studied further research is necessary to determine the generalizability of this treatment for clients.

 

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The lifetime prevalence rates for specific phobia ranged from 7 % to 11 % of the general population, placing it among the top five disorders (APA, 2000). Most specific phobias can be classified as animal type (e.g. spiders, snakes), natural environmental type (e.g. heights, thunder), situational type (e.g. driving, public speaking), or blood-injection-injury type (e.g. dentistry, disease). One in ten individuals seen by professional counselors may have a specific phobia or develop a specific phobia during their lifetime. It is important for professional counselors to have the knowledge and skills to effectively treat specific phobias. New technologies, such as virtual reality, are available that may improve the treatment process for both the client and the counselor. This article will present a brief overview of virtual reality therapy as a treatment for individuals with a specific phobia.

From the psychological paradigm, effective treatment for specific phobia has utilized cognitive and behavioral therapy (CBT) approaches of guided imagery, graded exposure, systematic desensitization, flooding, muscle relaxation, and assertiveness training (Maxmen & Ward, 1995). While CBT has been proved to be an effective treatment for specific phobia, systematic desensitization may be limited by lack of control on the environment by the counselor and reduced confidentiality (Krijn, Emmelkamp, Olafsson, & Biemond, 2004). The technique of systematic desensitization may include counselors accompanying their clients to environments, such as a crowded mall, elevator, or participating in a live driving situation. This technique has been used to gradually place clients within the feared situation. Therefore a client who was afraid of heights was taken into a glass elevator in a tall building. Each successive time the counselor accompanied the client into the elevator and traveled to the next highest floor. Difficulties with systematic desensitization included the amount of additional time involved in traveling and obtaining access to the object or situation (North, North, & Cobble, 2002). This challenge could include a professional counselor locating and obtaining access to a tall building, purchasing a ticket to accompany a client on an airplane, or handling live snakes and spiders.

Another challenge to the traditional approach included a reduction in ability to protect the confidentiality of the client (North et al.). When a counselor accompanies the client to a location outside of the therapy office, other individuals may determine that the client is a participant in counseling. This disclosure may be contrary to the preference of the client. In addition, the counselor has limited control over extra therapeutic factors under the traditional systematic desensitization approach (North et al.). Taking a client to a public location may introduce a number of variables to the therapy session; including the community and an unintended malfunction of the feared stimulus (e.g. unusual turbulence on an airplane ride, a spider biting the client causing an allergic reaction). Finally, due to the prevalence of specific phobias a final limitation may involve a professional counselor who is assigned to treat a client with specific phobia, but who also hold a specific phobia similar to the client. The professional counselors’ own fear of the specific phobia may prevent a counselor leading a systematic desensitization due to the low levels of therapeutic control over the variables involved.

Guided imagery is another traditional approach typically used by professional counselors to treat specific phobia. A barrier to the effectiveness of guided imagery may be limited by the ability of the client to vividly imagine the feared situation (North et al.). North reported several cases where guided imagery failed due to clients having difficulty immersing in the experience or the therapist having difficulty directing a client through the technique. This technique failure may be frustrating for both the client and the counselor. The potential drawbacks to the current use of commonly accepted techniques, such as systematic desensitization and guided imagery, and the advancement of technology have increased the investigation of virtual reality therapy as a treatment of specific phobia.

Virtual Reality as Treatment

In the past decade, virtual reality therapy has provided alternative methods for clinicians to activate and then modify the phobic reactions experienced by clients (Hodges et al., 1999; Krijn et al., 2004).The paradigm of virtual reality involves the belief that individuals who enter a virtual environment will be experience similar thoughts and feelings to their actual experience in the environment. Virtual reality devices work collectively to have clients behave as active participants in a virtual environment. The result produces the experience of immersion or the sense that the individual is present in the virtual environment. Virtual reality creates an experience in which the client feels that they are actually in the real world environment (e.g. in an airplane, on top of a building). This is reflected by the subjective distress and physical symptoms reported by clients immersed in a virtual environment. B.K. Wiederhold, Jang, Kim, and M. D. Wiederhold found that clients in virtual environments exhibited emotions similar to those expressed when confronted with the actual feared situation (2000).

Research has been conducted to investigate the use of virtual reality to address a number of disorders including Attention Deficit Disorder (M. M. North et al., 2002), Anorexia (Riva, Bacchetta, Baruffi, Rinaldi, & Molinari, 1999), Agoraphobia (Botella, Villa, Gracia-Palacios, Baños, Perpiña & Alcañiz, 2004), Antisocial Behavior (Pivik, McComas, Macfarlane, & Laflamme, 2002), Body Image (Perpiña, Botella, Baños, Marco, Alcañiz & Quero, 1999; Riva, Bacchetta, Baruffi, & Molinai, 2001), Claustrophobia (Botella, Baños, Villa, Perpiña, Garcia-Palacios, 2000), Depression (Difede & Hoffman, 2002), Post Traumatic Stress Disorder (Hodges et al., 1999; Parent & Thibault, 1998; B. O. Rothbaum et al., 2001), and Sexual Dysfunction (Riva et al., 2001). This paper will provide a brief overview of several outcome studies regarding the effectiveness of virtual reality in the treatment of specific phobias. The largest area of research has been on the use of virtual reality in the treatment of specific phobias including acrophobia, fear of spiders, fear of public speaking, and fear of driving.

Acrophobia

            As we become a more industrialized society, more individuals rely on interaction with tall buildings, bridges, and airplanes. Acrophobia is a specific phobia characterized by a fear of heights resulting in the avoidance of situations that would involve being high above the ground, such as in a elevator or an airplane. Emmelkamp, Krijn, Hulsbosch, Vries, Schuemie, and Van Der Mast conducted a study comparing three sessions of virtual reality versus three sessions of exposure in vivo for 33 patients who fulfilled the criteria for an acrophobia diagnosis (2002). The virtual environment was a replica of the exposure in vivo group environment, which included an escalator, fire escape, and roof top garden. Emmelkamp et al. did not find significant effect at p < .05 for the multivariate analysis for the repeated measure between the virtual reality and exposure group. However, upon analyzing the mean scores for anxiety, avoidance, and attitudes towards heights, Emmelkamp et al. found that the virtual reality group means were similar to the means of the individuals in the exposure in vivo group. This suggested that both treatments were relatively equally effective. The study was limited by utilizing self referred subjects to the treatment conditions rather than random assignment. Based upon the research design and the results reported, the conclusion to assume that virtual reality therapy was just as effective as exposure in vivo appears valid within the population measured, however the results should not be generalized.

A similar study examined acrophobia in a 61 year-old male in Korea (Choi, Jang, Ku, Shin, & Kim, 2001). The client received eight sessions of virtual reality therapy. The virtual reality therapy included immersion in a virtual open sided elevator traveling up a steel tower. The client also received four sessions of cognitive-behavioral therapy. Subjective units of distress were used to evaluate the client’s progress during the treatment and questionnaires to evaluate anxiety, acrophobia, and attitudes towards heights were used for pre and post treatment measurement. Choi et al. found that the subjective units of distress decreased between pre and post treatment and the effectiveness of treatment was reinforced by the client taking a trip to the top of the tallest building in Seoul and reporting little subjective distress. These results suggested that virtual reality and cognitive-behavioral therapy was an effective treatment for this specific client. It is not possible to generalize the results of this study, as it was based on the experience of one individual. It was also unclear whether the remediation of acrophobia was due to the virtual reality therapy or the addition of four sessions of cognitive-behavioral treatment.

Rothbaum, Hodges, Anderson, Price, and Smith conducted a study that involved 49 patients assigned to three groups of virtual reality therapy, exposure therapy, and a wait list group (2002). Rothbaum et al. found a significant effect at p < .05 for the repeated measure ANOVA for the virtual reality and standard exposure groups in reducing the clients’ fear of flying. However, upon using a t test to compare the post treatment scores between the virtual reality and standard exposure groups, it was found that the post treatment means were not significantly different. The results of the study demonstrate that virtual reality therapy was more effective than no treatment, but did not appear to be significantly more or less effective than the traditional exposure therapy. The small group sizes of 15 participants reduced the statistical power of ANOVA, which may have limited the ability to find significance difference on the post hoc test between virtual reality and exposure treatment. Based upon the research design and the results reported, the conclusion that virtual reality therapy and exposure therapy was more effective than no treatment appears to be appropriate.

Finally, Pauli conducted a study to determine the effectiveness of one session of virtual reality (VR) for individuals who had a fear of flying (2003). Forty-five clients diagnosed with acrophobia were randomly assigned to three groups; cognitive treatment with VR motion stimulation, cognitive treatment and VR without motion stimulation, and cognitive treatment without VR. Pauli  measured the clients’ fear of flying before treatment, after treatment, and six months after treatment. The results of the study demonstrated a significant reduction in fear of flying in both VR groups compared to the group that did not utilize VR. Based upon the research design and the results reported Pauli concluded that cognitive therapy with virtual reality therapy was more effective than cognitive therapy without virtual reality.

Fear of Spiders

            Spider Phobia is characterized by an anxiety response triggered by the exposure to spiders, which produces the avoidance of environments that may contain spiders (Carlin, Hoffman, & Weghorst, 1997). A case study conducted by Carlin et al. involved a 37 year old female who reported having incapacitating fear of spiders for approximately 16 years. The participant received 12 weekly one hour sessions of virtual reality therapy which included immersion in a virtual environment that consisted of a kitchen containing a large spider and spider web. A fear of spider’s questionnaire that was used to evaluate the client’s progress during the treatment showed a reduction of fear from 41 (high level of fear) to 17 (low level of fear). These results were reinforced by a follow-up with the client where she reported ceasing her daily behaviors where she checked for spiders. In addition this client reported engaging in a desired camping trip that she previously avoided due to the fear of encountering spiders. Although Carlin et al. reported a positive outcome, the client may have had a diagnosis of obsessive-compulsive tendencies with specific obsessions regarding checking for spiders, in addition to a specific phobia.

Garcia-Palacios, Hoffman, Carlin, Furness, and Botella conducted a study that compared an average of four sessions of virtual reality therapy to no treatment for the 23 patients who fulfilled criteria for specific phobia of spiders (2002). The virtual reality environment consisted of a kitchen that contained a large virtual tarantula. Through the course of the therapy the participants viewed, touched, and held a virtual spider. Garcia-Palacious et al. found significant effect at p < .05 for the 2 X 2 ANOVA that compared pre and post measures with the virtual therapy and the no treatment group. This was demonstrated by significant reduced scores on a fear of spider’s questionnaire, observations of the independent assessors, and reduced subjective anxiety levels following treatment. Furthermore, Garcia-Palacious et al. found that 83% of the participants previously diagnosed with specific phobia did not meet the criteria for specific phobia diagnosis following the treatment. Several limitations of the study included a small sample size and that the participants self referred to the experiment as extra credit for a class. This may have resulted to increase motivation by participants to do well in the treatment thereby increasing the possibility of Type 1 error.

Fear of Public Speaking

The fear of speaking in front of a group is often noted as one of the most common fears of the general public. B. K. Wiederhold and M. D. Wiederhold found that individuals who had a fear of public speaking experienced many of the same physical and cognitive reaction when speaking to a virtual audience (1998). Lee, Ku, Jang, D. H. Kim, Choi, I. Y. Kim, and S. I. Kim proposed a treatment for individuals who have a fear of public speaking (2002). Lee et al. created an experiment to have participants speak to a virtual group of people while the therapist controlled the reactions and responses of the virtual audience (2002). In this technique, the therapist was able to control the virtual audience to by more hostile or attentive to increase of decrease the anxiety experienced by the client. Although the virtual public speaking environment has not been empirically evaluated, Lee et al. hypothesized that virtual reality therapy may be successful in reducing the fear of public speaking (2002).

Harris conducted a study to investigate the effectiveness of virtual reality therapy in reducing public speaking anxiety (2002). Fourteen student’s participants were divided into two groups (VR group and no VR group). The virtual reality group participated in four weekly 15 minute sessions, while the no VR group were place on a wait list. The four VR sessions involved the participants speaking in three different situations including a dark unoccupied auditorium, sparsely occupied auditorium; auditorium filled with individuals who increasing attempted to distract the client by talking to each other. The experimental group members were measured on their subjective units of discomfort and their heart rates were measured during the VR sessions. All participants completed four self-report inventories (Personal Report of Confidence as a Speaker Inventory, Self-Evaluation Questionnaire, Liebowitz Social Anxiety Scale, and the Attitudes Towards Public Speaking Questionnaire) at both the pre and post treatment. Harris found a significant reduction (p < .05) in the anxiety of the participants due to participation in VR treatment based upon the self-report measures and physiological measures. Although these results were based upon a small sample size, they suggest that relatively brief (15 minutes) virtual reality treatment may be an effective method for reducing fear of public speaking in clients.

Fear of Driving

            Urban sprawl has increased the need for the use of both public and personal transportation. The ability to drive can be a necessary ability providing increased opportunities for clients in the community. Driving phobia can be characterized as an intense and persistent fear of driving that restricts a person from driving or permits driving only under considerable distress. Wald and Taylor conducted a case study with a client who met the criteria for the DSM-IV diagnosis of specific phobia (2002). The participant received three sessions of virtual reality driving during a ten day period. The virtual reality sessions included the client driving on a rural, residential and highway virtual environment. The client encountered on-coming cars, intersections, bridges, road construction, and other drivers pulling in front of the client’s vehicle. Subjective levels of distress scores that were used to evaluate the client’s progress decreased following each virtual reality therapy session. Upon a six month follow-up with the client, Wald and Taylor reported that the reduction in the client’s driving phobia was retained as evidenced by engaging in a variety of driving and self report regarding anxiety level. Although, these results suggested that virtual reality treatment was effective for this one client, these results should be taken with caution due to the use of self report for both the outcome and follow-up study.

            Another virtual reality driving simulation was conducted with seven clients who were recently discharged from an emergency room following an accident (Walshe, Lewis, Kim, O’Sullivan, & Wiederhold, 2003). The seven clients met the criteria for specific phobia and agreed to participate in sessions of virtual reality and game reality. The treatment involved the participants playing the driving simulation games of London Racer, Midtown Madness and Rally Championship, as well as, engaging in a virtual reality program that involved the participants driving on a rural road, negotiating traffic and road hazards. The participants also received traditional counseling that involved cognitive restructuring to dispute irrational beliefs and the clients were taught breathing exercises to reduce anxiety. All of the clients were given pretest and post test on scales that measured subjective rating of distress, fear of driving, post traumatic stress disorder, and depression. All of the participants’ scores significantly decreased (p < .05) on the outcome measures following participation in the virtual reality / video game experience. Walshe et al. was one of the first studies to examine the usefulness of video game play in treating specific phobia of driving. The video game play was combined with a traditional virtual reality simulator and cognitive behavior therapy which reduces the ability to determine the effect of video game play or virtual reality apart from the cognitive-behavioral therapy. Walshe et al. utilized a small sample size and no control group which reduces the generalizability of the conclusions.

Case Example – Fear of Driving

            The present case example described a brief one session inexpensive virtual reality experience for a client who met the diagnostic criteria for specific phobia - driving type.

The client was a 21 year-old female who had been in two car accidents and was seeking treatment due to stating that she has been unable to drive. In six sessions the professional counselor met with the client; however he failed to make progress utilizing traditional cognitive-behavioral approaches such as imaginal exposure therapy. In addition, the professional counselor prescribed homework associated with driving that was not completed by the client. Upon having a discussion with the client regarding her belief as to she believed would be a helpful treatment for her, the client remarked that she desired the professional counselor to accompany her in a live driving situation. Agency policy and personal preference prevented the professional counselor from participating in a systematic desensitization driving experience with the client. However, the professional counselor offered the client to participant an alternative driving situation based upon a virtual reality video game simulation experience.

            The equipment utilized for this technique included a Nintendo 64 video game system, a LCD wall projection unit, and a driving simulation game (Beetle Adventure Racing). The technique was provided in an empty conference room with the tables and chairs arranged in a manner simulating a vehicle (e.g. two front seats, two back seats, tables in front and on the sides). To increase the immersion experience, the professional counselor provided a CD player for the client to play her favorite music while participating in the driving experience. The professional counselor placed a doll in the backseat to represent the clients’ young daughter and the client was also permitted to have an unlit cigarette in her mouth, as she stated that she typically smoked while she drove.

            The driving scene was projected on the wall in front and the lights were turned off to provide the opportunity for the client to be immersed in the experience. The professional counselor was seated next to the client “in the passenger seat” facing the screen. The client utilized the video game controller to drive the vehicle on a rural road in the video game. The professional counselor monitored the client’s subjective units of distress (SUD’s). As the clients anxiety increased, she was given the opportunity to pull the video game car to the side of the road. When the client felt comfortable and her anxiety decreased, she then resumed participating in the video game. As the driving experience continued, the professional counselor utilized role play/imaginal techniques to assist the client in pretending that she was dropping her daughter off at a babysitter, driving to therapy and picking up fast food at a drive through. Following use of the 50 minute video game technique, the client was both visibly happy and stated how pleased she was with the experience. The client remarked that she was proud of herself that she was able to drive the vehicle. In addition, the client remarked that her “dream car” was a Volkswagen Beetle which by coincidence was the vehicle the client drove in the video game. At the end of the session the client stated that she desired to “go out and try the real thing.” Following the virtual reality experience the client returned for two final sessions to process termination from counseling. By the final counseling session the client reported that she had participated in a live driving experience and had re-obtained her driving permit. Although this case study involved a mix of cognitive-behavioral methods and lacked use of standardized assessment tool to assess the client prior and post virtual reality session, it was clear to the professional counselor that the use of the virtual reality video game experience was a significant catalyst for treatment with this specific client.

Equipment & Resources

Professional counselors who are interested in pursuing virtual reality therapy with their clients will need access to the appropriate computer equipment and resources for effective treatment. Although most professional counselors have access to computers, properly utilizing virtual reality therapy includes the professional counselor obtaining a couple hardware components not found on the typical agency or school computer. The basic components necessary to conduct virtual reality therapy consists of a computer, a virtual environment program (e.g. an glass elevator traveling to the top floor), input devices that allow the client to move and interact with the program (e.g. mouse or head tracking device, such as the VFX3D from Interactive Imaging Systems, and output devices that allow the client to experience the virtual environment (e.g. graphics and sound) (Davies, 2001). The minimum recommended minimum computer system to run a virtual reality program included a Pentium IV, 2GHz or faster processor, 256 megabytes of memory, 40 gigabyte hard drive; Sound Blaster Live soundcard, NVidia Ge Force 5600FX or better graphics card with at least 64 Mbytes (Virtually Better, n.d.). Users will also need the basic components of a computer such as a CD drive, mouse, speakers, monitor, keyboard and Windows XP operating system.

Icuiti Corporation (n.d.) is a distributor of virtual reality products and provides the equipment necessary for a clinician such as virtual reality glasses. An example of the minimum equipment available included a pair of V920 eyewear, which could be purchased for a couple hundred dollars. These glasses offer portable high resolution virtual reality display and audio through an ear bud (Icuiti Corporation). Other more complex devises include head trackers, gloves, and vests. The VirtuaTrack head tracker device provides clients with the experience of immersion in the environment by creating images that correspond to the head motion of looking up, down and side to side (Virtual Realities). An alternative to having the client use a mouse to interact within the environment would be to purchase a P5 glove. The P5 glove is a glove-like peripheral device that provides users interaction with 3D and virtual environments by allowing clients to experiences manipulating objects in a virtual environment (Virtual Realities). Finally, the Interactor Vest is a small back pack that allows the client to experience physical sensations that correspond to the virtual environment (Virtual Realities).

It is necessary for professional counselors to obtain or create virtual reality programs appropriate to the specific phobia of their clients. Technologically knowledgeable counselors can construct virtual environments by using the programs developed by Digital Element (n.d.). Separate programs can be purchased and be combined to create a virtual reality environment for the client. WorldBuilder 4.1 can be used as a standalone virtual reality environment. Additional packages with more specific graphical images (e.g. Model Shop 1.0, Verdant 1.6, Aurora Sky 1.0) can be incorporated to include more specific objects, plants, and environmental conditions (Digital Element, n.d.). 3Dlinks (n.d.) reported over 50 additional software programs varying in function and price that could be utilized to design virtual reality environments. The programs provides the freedom and ability to create 3D world environments that fits the needs of the client. These programs can provide the professional counselor the tools to construct a virtual reality environment tailored to the needs of the client.

Virtual reality therapy is currently being used by a variety of clinicians abroad. There are a number of companies who produce virtual reality equipment and software for clinicians. The following links provide general information, virtual reality therapy treatment centers, examples of virtual reality environments, and suppliers for virtual reality products.

General Information

CyberPsychology & Behavior - http://www.liebertpub.com/publication.aspx?pub_id=10

Virtually Better - http://www.virtuallybetter.com/

Virtual Reality Therapy

Virtual Reality Medical Center - http://www.vrphobia.com

Virtual Reality Treatment Center - http://www.vrtreatmentcenter.com

Weill Medical College of Cornell University - http://vrtreatment.com

Sample Virtual Reality Environments

Charles van der Mast & Merel Krijin (Technical University of Delft & University of Amsterdam) - http://mmi.tudelft.nl/~vrphobia/images.html

Products

Cybermind Interactive Nederland - http://www.cybermind.nl/home.html

Interactive Imaging Systems, Inc. - http://www.icuiti.com/

Virtual Realities, Inc. - http://www.vrealities.com/

If a professional counselor is unable to purchase the more expensive virtual reality equipment or software, they may consider experimenting with a less expensive alternative with their clients. This could include the use of a video game system (e.g. Nintendo Game Cube, Play Station 2, X-Box), an LCD projector, and a driving simulation game (e.g. Beetle Adventure Racing, Need for Speed, Virtua Racing, World Racing), and constructing a room to simulate the driving experience. A video game system can be purchased for between 100 and 200 dollars. The video game can be rented for minimal cost or purchased for around 50 dollars. Typically, community agencies and schools have LCD projects that staff can borrow. While the effectiveness of utilizing virtual reality video game technique to treat specific phobia is not clear, it may provide a useful line of research that could hold benefits for both clients and professional counselors.

Evaluation

Offering treatment by means of virtual reality holds several advantages and disadvantages. Banos, et al., 1999; Carlin, et al., 1997; Garcia-Palacious et al., 2001; Krijn et al., 2004; Riva, et al., 2001; Rizzo, et al, 1998; Rizzo & Schultheis, 2002; Virtually Better, n.d., provided an evaluation of virtual reality therapy reflected in the following table:

 

Advantages	Disadvantages
Increased safety and control by eliminating unpredictable real world environments	Simpler approaches, such as guided imagery, may be just as effective
Better protection of clients confidentiality	Cost and ability to use the equipment
Better chance of reimbursement due to shorter exposure sessions	Abuse by clinician due to ease of ability to create phobic experiences too intense for client
Attractive form of treatment due to being perceived as less threatening than exposure	May cause virtual reality sickness (e.g. nausea, sweating, dizziness, headache, etc.)
Ability to stop the virtual exposure for discussion or integration of other techniques

 

The benefit of utilizing virtual reality included the ability to create and control situations for the client. Unlike traditional systematic desensitization, virtual reality can provide a similar emotional response, but restricted in a controlled environment. This involved controlling both the type and delivery of the environment (Rizzo & Schultheis, 2002). A virtual reality simulation could provide an opportunity for clients to face situations that they anticipate as anxiety provoking without having to leave the safety of the counselors’ office. Remaining in the clinicians’ office also reduced the possibility of violations of confidentiality due to accompanying the client in real world community based situations (Virtually Better, n.d.). Another benefit identified by Rizzo and Schultheis included the ability of counselors to stop the virtual exposure for discussion or integration of other techniques within the treatment (2002). A final benefit may be the increased participation by clients in treatment. Currently only 12% to 30% of persons with specific phobia seek treatment (APA, 2000). Garcia-Palacious et al. reported that individuals with a fear of spiders were more likely to enroll in multi-session virtual therapy than in multi-session exposure therapy, due to perceiving VR treatment as safer than treatment where they would be exposed to a live spider (2001). Finally, the use of virtual reality technology that incorporates video game play may be particularly attractive to school counselors or counselors who work with children. Many children and adults enjoy and desire playing video games. Advances in technology and types of games relevant to specific phobias in children, may produce a nice technique attractive to both counselors and children.

The limitations of utilizing virtual reality include cost, potential of cybersickness, and adverse effects to the client. The major challenge in the past was the cost of the virtual reality equipment. However, technology has advanced and opened the way for low cost use for clinicians. Riva et al. found the necessary specification for an adequate virtual reality simulator involved working off of a portable computer that cost under $2000 and utilizing relatively low cost eyeglass displays and using fairly inexpensive input devices such as a mouse or joystick (2001). In the next several years the price of utilizing the equipment is expected to decrease, while the functionality in graphics processing and VR reality hardware is expected to increase. Another limitation to the use of virtual reality was experience of motion sickness during and following virtual reality therapy by some clients. Baños, Botella, and Perpiña explained that the virtual reality sickness was as a similar experience as sea sickness, and was caused by an incongruence between sensory cues of what is perceived and what is experienced by the body (1999). Continued development of hardware and software that reduces the perception of disconnect between actual and virtual environment should reduce occurrences of virtual reality sickness. One final caution with the use of virtual reality included possible negative effects from the treatment. Virtual reality provides the counselor with the abilities to easily create anxiety provoking experiences that may be too intense for the client, such as with giant spiders or extremely tall buildings. Carlin et al. (1997) reported an adverse effect of virtual reality therapy by a client who encountered a virtual therapy environment with an extremely large virtual tarantula. The client experienced strong emotional distress that lasted several hours beyond the therapy session as reported by the client (Carlin et al.). This suggests that the potential uses for virtual reality therapy should be careful evaluated to prevent negative effects to clients.

Virtual reality therapy offers potential benefits for the treatment of specific phobia. The integration of technological advances into the counseling process can be exciting, however clinicians must evaluate whether treatment can be accomplished with a simpler approach (Rizzo, Wiederhold & Buckwalter, 1998). Due to the limited amount of research currently available the effectiveness of virtual reality therapy compared to traditional measures remains unclear. Much of the research results are confounded due to studies with small sample sizes, lack of control groups or samples from biased populations. In addition, there was a paucity of research that evaluates the usability and affordability for professional counselors. The available research supports the conclusion that the use of virtual reality therapy produces benefits for clients with specific phobia when compared to clients receiving no treatment.

            The research in virtual reality therapy has several implications for professional counselors, counseling supervisors, and counselor education. The research suggested a position that virtual reality therapy may be a beneficial and efficient way of treating specific phobias. This perspective then implies that professional counselor would need to develop an understanding in computer technology and software beyond a surface understanding of word processing and internet use. Counseling supervisors would need to be aware of the potential benefits of counselors incorporating technology into the therapy they are conducting with their clients. A generation gap may exist between younger professional counselors who were raised with computers and feel comfortable using the available technology and supervisors comfortable with the traditional approaches to counseling. This may create conflict between the supervisor’s perspective and the counselor’s perspective as to the benefits of experimenting with the emergent techniques available. Counselor educators have recognized the importance of addressing the technological competence of professional counselor (CACREP, 2001). As technology continues to evolve, counselor education programs should take advantage of the ability to connect with computer science departments to increase the technological competency of counseling trainees.

This paper explored the use of virtual reality therapy with individuals who have a diagnosis of specific phobia. Findings of this study provided support to the perspective that virtual reality techniques may provide a useful technique to treat specific phobia. Research findings have demonstrated several statistically significant cases of improvement by clients who participated in virtual reality therapy. In addition, several case studies have shown improvement in single clients who participated in a virtual reality experience. Further studies with broader and more experimentally appropriate sampling procedure are recommended to determine the effectiveness of virtual reality therapy as a technique useful for clients with specific phobia.

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Author's Biography

Jake J. Protivnak is an Assistant Professor of Counseling in the Department of Counseling at Youngstown State University.  He can be reached at:  jjprotivnak@ysu.edu