CyberPsychology & BehaviorVolume 1, Number 3, 1998Mary Ann Liebert, Inc.

Virtual Reality Exposure Therapy (Fear of Flying):From a Private Practice Perspective

RICHARD A. KLEIN, Ph.D.

ABSTRACT

A new treatment modality has been introduced recently as an alternative to standard in vivoexposure therapy or other traditional therapeutic approaches. The Phobia Center™ is the firstnon-affiliated private practice in the United States to treat fear of flying (FOF) patients withVR exposure therapy. The preliminary results are very encouraging and support the efficacyof VR exposure therapy. The rationale for VR treatment for fear of flying and other anxietydisorders are examined, and factors incorporating the utilization of VR treatment in a privatepractice setting are explored.

FEAR OF FLYING

Air travel has become a ubiquitous modeof transportation for an ever-increasing

percentage of the population; and, it appearsthat this trend will only continue to increase as

we move into the next century. Although airtravel has become more convenient, comfort-able, time and cost efficient, and much safer,some individuals experience difficulty or a to-tal inability to fly due to an underlying psy-chological disorder. Fear of flying (FOF) is a

fairly common disorder that affects between 10to 20% of the population within the UnitedStates; it is estimated that approximately 25million individuals suffer from some form offear of flying.1'2 Individuals who experienceFOF attempt to cope with this "problem" byavoidance or by medicating themselves beforeand/or during the flight; it has been estimatedthat 20% of airline passengers depend on alco-hol or sedatives to deal with the fear and anx-

iety that are precipitated by FOF.1'3 In addition

The Phobia Center, 25200 Chagrin Boulevard, Suite 107,Beachwood, OH 44122.

to the personal implications of FOF, such as ca-

reer repercussions, social embarrassment, re-

stricted opportunities, financial implications,decreased feelings of self-worth, and stigmati-zation, FOF has a significant impact on the airtravel industry as a whole in terms of an esti-mated revenue loss of 1.6 billion dollars (1982dollars).3'4

The frequency of diagnostic factors underly-ing fear of flying is roughly bimodal in distri-bution. About one-half of the patients who ex-

perience fear of flying symptoms are diagnosedas having a specific phobia—DSM-IV:300.29(they are fearful of something happening to theaircraft, e.g., crashing). The other half of theFOF population are diagnosed as agoraphobicswith or without a history of panic disorders—DSM-IV: 300.21 or 300.22, respectively (they are

fearful of being trapped and experiencing a

panic attack.5The American Psychiatric Association's 4th

Edition of the Diagnostic and Statistical Manual6states that the essential feature of a specificphobia is "... a marked and persistent fear ofclearly discernable, circumscribed objects or

situations,"6 Adults recognize that in the pres-ence of the object or situation, or even in an-

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ticipation, that their anxiety or fear response isunreasonable or excessive; however, in spite ofthis awareness they are unable to control theiremotional and/or physiological response.

The essential feature of panic attacks are ". ..

a discrete period in which there is the suddenonset of intense apprehension, fearfulness, orterror . .. associated with feelings of impend-ing doom."6 Individuals who experience ago-raphobia and panic attacks as a part of FOFmay have a previous history of a panic disor-der, or the onset of their first reports of agora-phobia and panic attacks may coincide with is-sues that are circumscribed and relate only toFOF. As with the diagnosis of specific phobia,individuals who experience FOF either avoidcircumstances, i.e., flying, that may precipitatean intense negative response, or the individualmay endure the situation with intense dread.

VR FOF TREATMENT PROTOCOL

The FOF virtual reality exposure therapyconducted in our office is based on and followsthe treatment protocol established by Drs.Rothbaum and Hodges in their unpublishedtherapist manual, Virtually Better™ TherapistTreatment Manual for Virtual Reality ExposureTherapy of Fear of Flying.7'8 The Virtually BetterVR FOF treatment is to be used by experiencedclinicians that have been trained to use expo-sure therapy in their clinical practice. The man-

ual states ". . . if you would not be qualified totake a patient out for in vivo exposure, youshould not attempt Virtually Better™ expo-sure, either." (Virtually Better™ unpublishedmanual, 1997.)

Our FOF virtual reality exposure therapyconsists of three discrete segments: pretreat-ment assessment, FOF treatment, and post-treatment assessment.

Pretreatment assessment

The pretreatment assessment is designed toevaluate potential FOF patients (to determinehis or her appropriateness for treatment), andto identify the unique aspects of the patient'sFOF. Understanding the elements of the pa-tient's FOF enables the VR treatment to be tai-lored and individualized for each patient.

A number of standardized, written instru-ments are administered to each prospective pa-tient. Some of the instruments are measures

suggested in the Virtually Better Therapist'sTraining Manual. These instruments include:Questionnaire on Attitudes Toward Flying—QAF,3 Fear of Flying Interview—FOFT,5 State-Trait Anxiety Inventory—STAI,9 Self-Survey ofStress Responses—SSR,W Virtual Reality AirplaneScenarios—FOF Study Self-Ratings.8

Each of the above instruments is not admin-istered to all prospective patients. Based on an

initial telephone interview when the prospec-tive patient calls to schedule an appointment,a decision is made as to which instruments willbe administered.

Two additional instruments are administeredto all patients in the pretreatment assessment.The author included these two additional in-struments based on his clinical experience. Theseinstruments include: Psychological/Social HistoryQuestionnaire (Rainwater, G., 1984—in an un-

published computer manual), and MinnesotaMultiphasic Personality Interview—MMPI.10

Clinical interview

Prior to beginning VR treatment, materialgathered during the written portion of the pre-treatment assessment is discussed and evalu-ated in greater depth with the prospective pa-tient. At this time, the therapist begins to createan individualized treatment plan for the pa-tient. During the clinical interview, feedbackregarding their FOF issues and other treatmentoptions are provided to the patient. During theclinical interview the patient is given informa-tion regarding VR exposure therapy, an op-portunity to view the equipment, and ask anyquestions that might arise. Once these issuesare resolved, the patient then contracts fortreatment, receives and signs an informed con-sent form, and any financial issues (paymentand insurance reimbursement) are dealt with.

VR exposure treatment: Sessions 1-2/3Patients are typically seen in treatment once

a week. Prior to the VR exposure therapy, pa-tients are first provided instruction in relaxationtraining and thought-stopping techniques (theactual number of sessions depended on how

VIRTUAL EXPOSURE THERAPY (FEAR OF FLYING) 313

well the patients are able to master the tech-niques). The relaxation training and thought-stopping techniques are established techniquesthat clinicians have used for years. At the endof these initial sessions, patients are given"homework" assignments to practice their re-

laxation and thought-stopping training athome, at least twice a day. Progress reports are

obtained at the beginning of each session; ad-ditional training in these techniques or modifi-cations are instituted as the need arises.

Sessions 2/3 until completionOnce the patient displays a moderate success

in relaxation and thought-stopping the patientis ready to move into the actual VR exposuretherapy (see Fig. 1). The first VR session intro-duces the patient to the equipment and im-merses the patient into the VR experience. Forthe majority of the patients, there is an initialperiod of time, generally during the first ses-

sion, where the novelty of the VR experiencebecomes predominant. The patient is in a "vir-tual world" that shifts and changes, giving thepatient a sense of being immersed in and ac-

tively interacting with the virtual aircraft.The initial novelty of the virtual reality ex-

perience generally lasts approximately 20-25min. The focus then shifts from the novelty ofexperiencing a virtual aircraft to experiencingstimuli that arouses some level of anxiety, suchas the engine cowling, the wing of the aircraft,or the confines of the aircraft cabin. A few pa-tients initially had difficulty in relating to thevirtual reality experience. Over the next sessionor two, with encouragement, the patient typi-cally begins to immerse himself/herself in thevirtual environment.

During each session SUDs, or SubjectiveUnits of Discomfort, are obtained from the pa-tient at the beginning of the session and every5 min during the VR portion of the session. TheSUDs rating measure on a 0-100 scale the levelof anxiety or discomfort the patient is experi-encing in the virtual aircraft. The SUDs score

assists the therapist in individualizing the VRexperience for the patient.

Moving from the first scenario (sitting in theaircraft parked at the terminal with the enginesoff) to the second scenario (parked at the ter-

minal, with the engines on) adds a second sen-

sory domain, auditory queues, to the visualstimuli.

During the first two scenarios the aircraft andthe patient remain stationary. Scenario 3 moves

the aircraft away from the terminal and downto the taxiway. With this scenario movementbecomes the focus of the VR experience as thepatient watches out the aircraft window as theaircraft taxies back and forth along the tarmac.

The next scenario (takeoff, smooth flight, andlanding) is where patients spend the majorityof their VR treatment. When the patient con-

templates moving into the flight portion of theVR treatment, the patient seems to be experi-encing two competing feelings. One is a sense

of heightened anticipatory anxiety, the time hascome to confront the fear "head on." The otherfeeling is a sense of accomplishment that theyhave progressed in their treatment and are ableto conquer a significant aspect of their FOF.

During this phase of treatment, once the pa-tient is comfortable with the smooth flight,treatment usually involves incorporating as

many "touch and goes" (four to five per ses-

sion) as we can accomplish during the session,and as many as the patient contracts for. In a

"touch and go" the aircraft takes off, flies innonturbulent weather for 3-5 min, and thenlands; this is repeated over and over. Obvi-ously, this maneuver is impossible in a real air-craft, and reflects the remarkableness and flex-ibility of virtual reality treatment.

The last scenario (thunderstorm or turbulentflight) is the final stage. Patients comment thatthe thunderstorm is very real, and certainlyelicits anxious feelings; however, for a numberof patients the thunderstorm scenario seems al-most anticlimactic. They accomplished thetakeoff, flight, and landing, and once they had"passed" this stage they feel much more secure

in their ability to accomplish an in vivo flight.Paralleling the VR treatment are homework

assignments, such as continued relaxationtraining or visiting an airport that patients needto accomplish between treatment sessions. Thefocus of treatment and of the homework as-

signments is to gradually move the patient to-ward taking an actual flight.

Over the course of treatment all patients whobegan VR exposure therapy at our office re-

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vealed reductions in every measure of anxietyand fear related to flying. In addition, self-state-ments about flying also changed as the patientprogressed though the VR treatment. How-ever, unless these factors could translate intoactual changes in behavior, the changes did notmeet the ultimate criteria: was the patient ableto actually fly after treatment? In order to move

the patient toward this goal, the therapist sug-gested, supported, and encouraged the actualgoal of a short flight (20-30 min duration) as afinal goal the patient should be "keeping inmind" as he/she moved through the variousaspects of VR treatment. This goal was notmandated as a requirement of treatment, norwould the patient be considered a failure if theydid not accomplish this in vivo flight. The goalof an actual flight was introduced early in treat-ment, communicating that an actual flightwould help the patient accomplish their statedgoal and would assist in making this antici-pated change in behavior more permanent.Posttreatment assessment

Upon completion of treatment patients are

requested to complete selected preassessmentmeasures to determine the effectiveness oftreatment. In addition, during their actualflight patients are requested to complete an in-flight questionnaire that includes SUDs levelspre-, during, and postflight. A follow-up inter-view is held with each patient after completionof their actual flight.

FIG. 1. VR therapy session (Photo © Polk Photography).

CASE STUDY

Joan is a retired, 66-year-old, masters' levelteacher who had not flown in over 30 years.Approximately a year ago she attempted a

flight to Florida. Arrangements were made,tickets were purchased, and plans were madeto meet with friends; however, as the time gotcloser her anxiety increased markedly. Joan be-gan to experience physical problems, such aschest pain, and thought, "my angina or hiatalhernia was acting up again." Once she can-celled her flight her symptoms went away.

As I was gathering background information,Joan indicated that her mother experienced fearof flying, but in spite of her mother's fears, Joanflew to some degree. That was until her fathersuddenly died of a heart attack. Shortly afterhis death Joan began to experience panic at-tacks; these panic attacks were so severe thatJoan had to give up teaching for a semester.

Gradually, as the panic attacks subsided, Joanwas able to return to teaching, but she was no

longer able to fly due to experiencing panic at-tacks while flying. She occasionally flew withher mother to assist her with her fear of flying.Now Joan admitted that she used her mother'sfear of flying as an excuse to avoid flying alto-gether.

Joan described her concern of flying as, "...not what was going to happen to the plane, butwhat is going to happen within myself." Theworst thing about flying is, "knowing that I am

trapped." On all measures of FOF Joan's scoresreflected intense anxiety and fear. She indi-cated that just sitting in the plane, parked at theterminal, with the engines off reflected signifi-cant anxiety (her score on this scenario was 70out of a potential 100). Taxiing yielded an ini-tial score of 90, while take off was 100—maxi-mum, panic-level anxiety.

Joan began treatment with a specific empha-sis on relaxation training, attempting to give herthe ability to gain control over her physiologi-cal response to anxiety provoking stimuli. Joanhad a number of actual physical problems, andunderlying emotional factors tended to exacer-bate her sensitivity and response to somatic con-cerns. Our concern was that with her preoccu-pation of somatic symptoms it would be verydifficult to focus and deal with the VR scenar-

VIRTUAL EXPOSURE THERAPY (FEAR OF FLYING) 315

ios unless these bodily concerns were resolvedprior to initiating the VR portion of treatment.

Once we moved into the VR, Joan had diffi-culty in immersing herself in the VR—it washard to make the VR real. This apparently wassome initial resistance in allowing herself to get"in touch" with her fears and anxieties. By ses-sion 3, Joan had made the transition into thevirtual aircraft and had begun to feel fears as-

sociated with flying. During these sessions sheinitiated self-talk statements, "I'm not going toscream . . . I'm going to be fine . . . take a deepbreath."

Joan completed a total of seven sessions, overthe course of 4 months, with illnesses and hol-idays extending the anticipated length of treat-ment. Finally, Joan felt ready to challenge herfear of flying, and felt that she was ready to ter-minate treatment. She indicated that she was

going to try a real flight and would contact usafter she had completed this task. For severalweeks we did not hear from Joan, and we werenot sure whether she could make the transitionfrom the VR flying to in vivo flying.

Joan excitedly contacted the office, inform-ing us that she had just returned from a trip,via plane, to New York. As Joan left our office,at her last session, she was given a "Test FlightSelf-Monitoring Sheet" to complete just priorto boarding, during the flight, and once landed.Her comments reflected anxiety in the 30^10SUDs level, with increased anxiety due to ahalf-hour delay in take off and a full plane. Sheindicated that she "... had a few trapped feel-ings, but breathing and imagery (thought-stop-ping techniques) dispelled those." She con-

cluded her comments by stating, "I feel that I'llalways have some anxiety, but I know that Iwill fly when I have to."

SUMMARY AND CONCLUSIONS

Virtual Reality Exposure Therapy has beenintroduced recently as an alternative to stan-dard in vivo exposure therapy or other tradi-tional therapeutic approaches.11 Over the last 6months, our office has treated a total of 12 pa-tients. Of our 12 patients, six have flown suc-

cessfully, three are in the early portions of treat-ment, one is completing the last phase of

treatment and is preparing to fly over the nextmonth or so. One patient has not flown; how-ever, her stated goal was to feel comfortableand be able to fly if she desired to do so; shestated that VR treatment met her stated goals.One patient has not flown and has unilaterally,terminated treatment. His pre-/posttreatmentscores reflected a significant reduction in anx-

iety and fear of flying; however, he was not ableto make the transfer to an in vivo flight.

VR exposure therapy is viewed as a poten-tially efficient, time- and cost-effective treat-ment for fear of flying and, implicitly, otheranxiety disorders. There are a number of sig-nificant benefits to VR exposure therapy com-

pared to other modes of treatment, includingin vivo treatment. VR treatment offers the pa-tient and therapist significant control in virtualenvironments compared to in vivo environ-ments. Situations that elicit a fearful responsecan be repeated over and over to facilitate ha-bituation; this is not feasible in an in vivo en-

vironment. In addition, because the patient isin control of the situation and can terminate thescenario, at a moment's notice, patients will bemore willing to undergo VR exposure therapycompared to in vivo treatment. Patients whohave difficulty with other existing treatments,such as imagery, are more likely to be able to"immerse" themselves in the VR environment.VR exposure therapy also provides time andcost savings to patients, as all VR treatment canbe conducted in the therapist's office, ratherthan away from the therapist's office.

Current VR exposure therapy is still in itsearly development. Current limitations incomputer hardware and software limit the de-finition of the graphics. Due to the limited res-

olution patients have some difficulty in expe-riencing a sense of "presence." Almost everypatient commented on this aspect of the VR ex-

perience; however, most of our patients, to a

large degree, were able to enter into the vari-ous scenarios. Also, because of the emergingtechnology, the head-mounted display (HMD)tends to be somewhat cumbersome and heavy;some patients have difficulty in holding theirhead erect in the VR session. Newer models are

becoming available that are lighter in weightand resolve some of the difficulties that our pa-tients have reported. Also, the initial cost of the

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"turn-key" system (hardware and software)may be prohibitively expensive for many clin-icians. Three years ago, the cost of the equip-ment, computer, and peripherals, was approx-imately $250,000; 6 months ago the cost haddropped by a factor of 10. Hopefully, thesecosts will drop again and be within the rangeof many private practice clinicians.

The stated goal of our involvement with VRexposure therapy was to move treatment outof the laboratory setting and begin to treat ac-

tual FOF patients, on a fee-for-service basis. Wedid not plan to conduct research comparing theeffectiveness of VR exposure therapy to othermodes of treatment. Clearly, research is neededin this area. However, our experience with VRexposure therapy, as evidenced by our case

study, appears to quite clearly indicate the ef-fectiveness and power of this treatment modal-ity. VR treatment will have significance in thetreatment of phobias and other related anxietydisorders as the technique moves from the lab-oratory setting into clinical practice.

REFERENCES

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3. Howard, W.A., Murphy, S.M., and Clarke, J.C. (1983).

The nature and treatment of fear of flying: A con-

trolled investigation. Behavior Therapy, 14, 557-567.4. Greist, J.H., and Greist, G.L. (1981). Fearless flying: A

passenger guide to modern airplane travel. Chicago: Nel-son Hall.

5. McNally, R.J., and Loura, CE. (1992). Fear of flyingin agoraphobia and simple phobia: Distinguishingfeatures. Journal of Anxiety Disorders, 6, 319-324.

6. American Psychiatric Association. (1994). Diagnosticand statistical manual of mental disorders (4th ed.).Washington, DC: Author.

7. Rothbaum, B.O., Hedges, L.F., Kooper, R., Opdyke,D., Williford, J., and North, M.M. (1996). Effectivenessof virtual reality graded exposure in the treatment ofacrophobia. American Journal of Psychiatry, 152,626-628.

8. Rothbaum, B.O., Hedges, L., Watron, B.A., Kessler,G.D., and Opdyke, D. (1997). Virtual reality exposuretherapy in the treatment of fear of flying: A case re-

port. Behaviour Research and Therapy, 34, 477-481.9. Spielberger, CD., Gorsuch, R.L., and Lushene, R.E.

(1970). Manual for the State-Trait Anxiety Inventory (self-evaluation questionnaire). Palo Alto, CA: ConsultingPsychologists Press.

10. Hathaway, S., and McKinley, C. (1970). Minnesotamultiphasic personality inventory. Minneapolis, MN:The Psychological Corporation.

11. Hodges, L.F., Rothbaum, B.O., Kooper, R., Opdyke,D., Meyer, I., North, M., de Graff, J.J., and Williford,J. (1995). Virtual environments for exposure therapy.IEEE Computer Journal, July, 27-34.

Address reprint requests to:Richard A. Klein, Ph.D.

The Phobia Center,25200 Chagrin Blvd., Suite 107,

Beachwood, OH 44122

E-mail: phobiacenter@worldnet.att.net