2016 XVIII Symposium on Virtual and Augmented Reality
VirtualPhobia: A Model for Virtual Therapy of Phobias
Sherazade Shunnaq
Department of Computer Science
Unisinos
São Leopoldo, Brazil
e-mail: zady.shq@gmail.com
Abstract— This study proposes a tool model for phobia
treatments using exposure therapy and virtual reality. The
model goal is to represent a system that enables the
treatment of several phobias with different techniques,
through the immersion of the patient in a virtual
environment with head-mounted displays, supporting the
addition of new modules of techniques or phobias. The
present work seeks to propose a broader and more flexible
virtual therapy system and obtaining a more current
solution. For the evaluation of the applicability of this model,
a prototype was developed with support to the treatments of
flooding, implosion, rationalization and systematic
desensitization, as well as support to more than one phobia.
The prototype was tested with volunteers to evaluate the
levels of reality, immersion and anxiety caused to analyze the
possibility of the use of this tool to support phobia
treatments. At the end of this study, the results showed that
the developed model is applicable, and that virtual reality
has great strength when applied to human’s psychology,
being that 80% of the participants reported feeling afraid or
having other characteristics of anxiety.
Keywords: Virtual Reality; Virtual Therapy; VRET;
Phobias; Immersion.
I. INTRODUCTION
In the last years, the computer graphics processing
capacity has increased quickly and constantly as well as
the quality of this week screens. This advancement enables
the creation of new devices and even the reinvention of
others with more quality and effectiveness.
At the same time, society has been advancing and its
complexity has been increasing, needing more advanced
solutions for more complex issues. The appearance of new
diseases, new issues, new experiences and new fears can
be noted as well. Phobias, or the exaggerated fear of
something or a situation [1], is not something new despite
several new phobias emerging in the last decades such as
the technophobia or the nomophobia (fear or anxiety of
being out of mobile contact).
The same way that technology advances, other science
areas tend to advance and make use of new technologies.
In medicine, for example, robotics has been used for years
helping surgeries and prosthesis controlled by microchips
to substitute lost members [2].
In psychology, some treatments can make use of new
devices. In the last decade, the term “Virtual Reality
Therapy” has been used more commonly, where virtual
reality is applied in several treatments such as PTSD.
Virtual reality therapy facilitates the treatment of
several disorders, as some of the feared situations can be
hard to replicate as the fear of travelling by plane or public
978-1-5090-4149-7/16 $31.00 © 2016 IEEE
DOI 10.1109/SVR.2016.20
Mateus Raeder
Department of Computer Science
Unisinos
São Leopoldo, Brazil
e-mail: mraeder@unisinos.br
speaking. With the use of virtual reality, it is possible to
simulate a plane trip, animals, high places, crowds, war
and other situations that might cause fear or anxiety and
are hard or impossible to replicate physically.
The virtual reality therapy solutions are hard to be
found in clinics, besides having a high cost and using
outdated devices and graphics as there has not been a big
investment in the field in the last years.
This research proposes a tool model to assist the
treatment of psychological disorders, enabling the use of
the main treatment techniques as systematic
desensitization where a patient is gradually exposed to the
object of fear that causes panic or anxiety, or flooding,
where the patient is exposed to the highest level of fear
possible. This paper proposes a model to support many
techniques and different types of phobias. Also, it proposes
the use of more economically accessible gadgets that are
usually created for entertainment.
II. THEORY
A. Phobias
Phobias are specific types of fear [3], where an
individual is afraid of being in a situation and when facing
it, has a fear of the possible consequences of it such as
falling, dying and feeling pain.
Beck, Emery and Greenberg explain that the object of
fear can be realistic (something that actually represents a
risk, as fear of heights) or unrealistic (does not represent
risk, as clowns) [3]. The response to this phobia may vary
from anxiety to panic.
The anxiety or anguish is, as Rojas defines, “a feeling
of anguishness, narrowness and stenosis”. And fear is
defined as “a specific awe, determined and objective
towards something external to us and approached bringing
disquietude, unrest, alarm” [1].
As previousty mentioned, phobia is an uncontrollable
fear that causes panic and anxiety. This fear and anxiety is
in excess controls the individual. According to Rojas, there
is a possibility for anxiety to become a phobia as well as a
phobia can make its way back with the appropriate
treatment [1].
According to Beck, Emery e Greenberg, phobias can
be developed for several reasons. In adults, many phobias
can be attributed to traumatic events that might have
happened during childhood or in the beginning of
adulthood [3] and left marks.
Another type of phobia related to childhood is the
phobia by fixation. Where a child is fixated on a fear
during his development and this fear evolves into a phobia.
There is also specific phobias that are not attributed to any
59
traumatic event or fixation. An example is the phobia of
blood, where a strong physical reaction happens during
visual or physical contact with blood.
B. Phobia Treatments
The template is designed so that author affiliations are
not repeated each time for multiple authors of the same
affiliation. Please keep your affiliations as succinct as
possible (for example, do not differentiate among
departments of the same organization). This template was
designed for two affiliations.
1) Cognitive Behavioural Therapy (CBT):
According to Gentil [4], the objective of treatments
behavioural therapy is to decrease and if possible
extinguish anxiety symptoms. It uses techniques such as
systematic desensitization, flooding and implosion that can
be applied with real exposure or unreal exposure, such as
imagination.
Cognitive treatments have the objective of modifying
the way a patient thinks through logic and the substitution
of irrational thoughts with more rational thoughts. In this
modality, techniques such as cognitive restructuring and
rational-emotional therapy are used to teach self control
through cognition.
2) Medication:
According to Gentil [4], there are many discussions
regarding the efficiency of the use of medications such as
benzenatol to treat phobias. The most common is to
combine medication with psychological treatments.
In other cases, such as phobia of plane flights, other
substances can be used as relaxants and alcohol to help
them through the experience.
3) Systematic Desensitization:
Systematic desensitization was developed by Joseph
Wolpe and was the first effective technique for phobia
treatment [4]. It can be done through hypnotherapy,
imagination or other methods where the psychologist
makes the patient face his fears gradually replacing the
memory of anxiety with calmness.
The treatment had three main levels. Firstly, the patient
goes into a relaxed mode and then the therapist establishes
a hierarchy with fear levels according to the patient’s
response to the leveling. At last, the patient is gradually
exposed from the level that causes less fear to the level that
causes more fear to desensitize him.
4) Flooding and Implosion:
Flooding is an implosive therapy where the patient is
exposed to his highest level of fear. This happens usually
through real contact, but can be done using imagination,
virtual reality or other techniques as the therapist finds
suitable [5]. For example, a therapist puts the patient in
contact with a real spider.
The implosion technique was created by Stampfl and
Lewis [6]. In this king of treatment, the therapist makes the
patient have contact with a high level of fear using
imagination, images, sounds and videos. One of the keys is
to bombard him with details and talking about the origins
of his fear. For example, the therapist shows the patient
pictures and videos of spiders and narrates how scary a
spider looks and moves.
5) Interoceptive Therapy:
The use of this therapy is very common against anxiety
disorders and is focused on the symptoms of the phobia.
60
Being able to significantly decrease the physical effects
through breathing techniques and similar exercises that the
patient can apply during the moment of fear [6].
6) Hypnosis:
The use of hypnosis in the context of phobia treatments
has the objective of altering the cerebral activity. This
technique is frequently used and can be applied along with
other treatments for better results. It can also be used as a
resource for other treatments such as systematic
desensitization to insert the patient in a specific situation or
flooding, where hypnosis is used to stimulate the patient’s
fear.
C. Virtual Reality
Alexandre Cardoso defines virtual reality as “A field
that pursuits to create a new way of interacting with
computers” [7]. It is a more immersive alternative of user
interface, getting rid of, but not excluding, the traditional
combination of screen, keyboard and mouse.
It can be defined and a new philosophy of interface
with greater immersion to free the user from the two-
dimensional environment, with real-time interactions to
create the sense of reality to the user.
The field has grown a lot in the last years, and along
with it emerging new applications merging it with different
areas such as psychology, that could use very well the
support of virtual reality.
D. Related Work
This section presents some of the work related to
virtual reality exposure therapy.
1) The Treatment of Fear of Flying: A Controlled
Study of Imaginal and Virtual Reality Graded Exposure
Therapy [8]:
This research is a comparative work between virtual
reality exposure therapy and imagination therapy and
verify their effectiveness. The tests were made with
patients with different degrees of phobia randomly divided
between therapy using imagination and a therapy software
developed by Brenda K. using a head-monted display.
2) ARGAMAN: Rapid Deployment Virtual Reality
System for PTSD Rehabilitation [9]:
Argaman was developed in Israel with the objective to
help with the treatment of PTSD using systematic
desensitization and virtual therapy. The developed tool
reproduces the scenarios that originated the trauma and has
different intensity phases to support the immersion is steps.
3) VitualRET [10]:
This set of software and hardware enables the
treatment of phobias such as the fear of insects and
claustrophobia using systematic desensitization.
4) Comparison with VirtualPhobia:
The proposed model in this research approaches
several treatment methods, differently from other
researches that use systematic desensitization.
The fact that the tool is structured in modules makes it
easier to add new techniques as well as new phobias to be
treated.
Another important factor is the use of newer and more
accessible devices, such as the Oculus Rift e other gadgets
used for entertainment and easily found, like videogame
controls. Most of the researches use older devices and
graphics with lower quality, which decreases the user’s
immersion.
III. PROPOSED MODEL
The tool model has the objective of helping with the
treatment of different types of phobias, with more than one
possibility of technique to apply. The phobias and their
treatments are separated into modules enabling the option
of adding new customized levels such as a scene with a
specific number of animals and new developed modules.
Each phobia module is specific for a theme and is
composed of different treatment techniques, as shown in
figure 1. Treatments with systematic desensitization have
several levels beginning with the lease feared to the
highest level. Each level has new changes, such as less
light, more sound effects, more objects or animals, more
details or other factors that can make the environment
scarier.
As for techniques such as flooding, the modules
support different “high levels” to be chosen from
according to the patient’s profile.
On the other hand, other techniques can have a
different approach using virtual reality, such as treatments
based on cognitive therapy, where new elements inside the
virtual environment can be used to help with the
rationalization of the fear, as a guided environment with
instructions and logical expressions to help the patient.
Figure 1. VirtualPhobia’s Model
After evaluating the patient, the therapist choses the
treatment best suited and if necessary, the more
appropriate start level according to the patient’s phobia.
During the sessions, the therapist will change level
according to the patient’s progress until the treatment’s
conclusion.
This model was reviewed by two psychologists to
verify if the procedures were understood correctly and are
applicable to the proposed idea.
A. Development
A prototype was developed to analyse the proposed
model in this research. Two phobia modules were
developed: acrophobia (exaggerated fear of heights) and
arachnophobia (exaggerated fear spiders). The tool was
developed supporting the head-mounted display Oculus
61
Rift [11] and the scenes were developed to support
implosion, flooding, systematic desensitization and
rationalization to evaluate the possibility of supporting
different treatments using exposure with virtual reality.
The development of the scenarios was as follows:
• Systematic desensitization for acrophobia: several
difficulty levels were created. The initial levels used small
bridges with different heights that should be crossed by the
user, and the highest levels reproduces tall buildings and
the user had to cross the using a wood board;
• Flooding for acrophobia: a scene was created where a
patient should cross very high buildings using wood
boards with different inclinations. The scene used many
sound effects, such as wind and the sound of creaking
wood. At the end, the user can jump off the highest
building. The main goal of this scene is to generate the
highest possible fear the patient can handle, which should
be determined by the doctor handling the tool;
• Rationalization for arachnophobia: a scene was
created were the user had to be virtually close to a glass
box with a spider inside, receiving explanatory texts about
the situation the user is exposed to using logic to reduce
anxiety;
• Flooding for arachnophobia: an environment was
created where the patient has to stay inside a room for a
determined period without exiting, this room is filled with
spiders: on the bed, furniture, floor, and walls. This scene
uses sound effects and movement;
• Implosions for arachnophobia: an environment was
developed showing several images of spiders to
accompany the doctor’s voice incentive.
Figure 2. Scenes from the prototype
The Oculus Rift was the device of choice for being an
innovative and relatively cheap technology. The fact that it
is a product with a lot of visibility and focus in
entertainment makes it a great candidate for receiving
frequent upgrades and improving constantly. The
prototype was developed using Unity Pro 4.0 [12], a game
engine with easy support for VR development and an
intuitive interface, as well as easy integration with other
gadgets such as the Leap Motion [13]. Some scenes from
the prototype are presented in figure 2.
IV. DISCUSSION AND TESTS
Two questionnaires using the Likert scale [14] were
made to analyze the tool model. One before the sessions,
where the participants answered 25 questions with
personal information such as name, age, health issues and
questions about fear levels and the existence of phobias.
The post-test quiz had 26 questions about the
experiment, with the following main items:
• Side effects: if he felt nausea, experienced vomit, etc;
 • Environment quality: From graphics quality to the
level of reality and the object’s response to the user;
• Anxiety, fear and relaxation levels: Such as “Which
level of anxiety did you feel in a given experiment?” and if
the participant felt suffocated for not being able to quit the
session, if he experienced sweat or felt relaxed through the
first levels;
• Opinions about the prototype;
• Immersion levels: perception of the real world during
the tests, such as external sounds, room temperature and
close people;
The tests were made individually with 20 volunteers
between 20 and 65 years old, with an average age of 30
years old and different levels of fear. None of the
participants had a diagnosed phobia.
The volunteers received a brief explanation about
virtual reality, phobias and the proposed model and signed
a consent form before starting the experiment. Then they
tested the scenes for arachnophobia with flooding and
acrophobia with systematic desensitization and flooding,
as shown in examples in figure 3.
V. RESULTS
Based on the collected data from the questionnaires
and notes during the sessions, an analysis of the prototype
was made.
In the pre-test quiz, the participants were asked about
their fear and anxiety levels towards spiders based on
previous experiences. After the test, the volunteers were
asked about their anxiety levels during the session. The
figure 4 shows a comparison between the anxiety felt in
real life and using virtual reality.
As it can be noted in the tested cases, the levels of
anxiety in the real world and in virtual reality are very
close.
The levels for determining anxiety took under advice
the Hamilton scale [1], where in each characteristic there
are four levels of anxiety (from absent to very strong).

Figure 3. Volunteers testing the prototype

Figure 4. Comparison between the anxiety felt in real life and in virtual
reality with arachnophobia case
The flooding technique was selected for the test to
measure if it is possible to reach fear and anxiety levels
The same questions about anxiety and discomfort were
using the tool, enabling the comparison between the fear
applied to the acrophobia tests, as shown in figure 5. It is
levels that the participants reported to feel in reality and
visibly notable the resemblance between the participants’
the levels felt using virtual reality.
reaction to situations in real life and the virtual
The systematic desensitization was selected to analyze
environment.
if the initial levels were able to create the needed
relaxation for the treatment’s success, as well as if the
higher levels caused any level of anxiety, otherwise the
levels would not have impact on the patient and there
would be no real progress because the relaxation was not
created through desensitization.
The participants were oriented not to talk during the
test scenes and to stand up for more immersion, as well as
not to remove the Oculus Rift before the end of the session
unless needed. The sessions lasted between 30 and 40
minutes and the tools used were a laptop, and Oculus Rift,
an earphone, a mouse and a joystick.
In addition, some recurrent sessions were made with
one of the volunteers, were the volunteer participated in
Figure 5. Comparison between anxiety felt in real life and in virtual
four sessions (one each week) to analyze his behavior reality with acrophobia case
regarding the tool.
In the last session, some physical stimuli were The participants were asked if they felt relaxed in the
introduced to analyze the change these additions would initial levels of systematic desensitization. Between the
cause to the tool. More virtual reality immersion was volunteers, 85% of them felt relaxed in the initial levels.
introduced using rubber spiders, wood boards and a Leap This point is extremely important for the treatment’s
Motion [13] device to capture the user’s hand movements success because the technique’s base is the patient feeling
and replicate them inside the virtual environment. The relaxed to detach the fear from the experience. With cases
stacked boards are placed under the volunteer and can be where the patient doesn’t feel relaxed there’s a need of
shaken manually to mimic what the patient would feel if help from the doctor’s side through specific methods.
losing balance from a high place. Regarding the tool, the participants were asked about
the quality of the tested environments. Most of the

62
volunteers thought the quality was good, and 85% of them
judged to be correct or completely correct the phrase “I felt
that the environment and animals were responding to me”,
which demonstrates satisfaction regarding the
environment.
Also, other questions were made to analyze the levels
of immersion of users, such as questions about their
capacity to be aware of the real world during the tests.
As shown in figure 6, most of the volunteers told felt
some level of unconsciousness regarding the real world
around them. One of the main factors used for a better
immersion is the use of headphones and sound effects.
At the end of the acrophobia test, the participants were
asked to jump off the highest building in the virtual world.
As a result, 20% of the participants refused to jump. This
shows clearly that they were impacted by the use of virtual
reality.
Figure 6. Perception of the real world during the experiment
Another factor studied was the side effects that the
participants felt during the tests, 80% of them reported to
feel or demonstrated some sort of effect such as crying,
screaming, nausea, panic, trying to run and leg tremors.
Most of the participants tried to grab the table in front of
them or the laptop for support during the acrophobia test.
During the four recurrent sessions made with one
volunteer, the anxiety showed to stabilize or decrease until
a new element was inserted. In the third session, the
participant finally accepted to jump off the building and
returned to only look down in the fourth session because of
the new physical stimulation (a wooden board). Figure 7
shows the simple environment set up for the tests, two
wooden boards that could be shaken to create a deeper
immersion.
Figure 7. Test environment
Another important point were the volunteer’s reactions
throughout the sessions. In the first two sessions it can be
noted that she leaned her body while descending to another
building and holding on to the laptop, showing a great
immersion in the virtual world. As well as feeling the need
to vomit and sweating when asked to jump off the building
and losing balance on the wooden board sometimes.
63
The participant described the session with physical
stimulation as an intense experience.
VI. CONCLUSION
Virtual reality is going through a rebirth time in the
market, creating new possibilities of innovation in several
fields. There is no doubt that psychology is one of those
fields. From phobia treatments to the rehabilitation of
patients with PTSD, the use of VR can change the way we
people deal with their problems.
The analysis made on the prototype created the
following points:
• Techniques such as systematic desensitization,
flooding and implosion can be replicated using a virtual
environment;
• Using a module structure, we have an easy tool that
could receive new functionalities and support new
treatments and phobias;
• With the appropriate tools, it is possible to unite
several new technologies. During the prototype’s
development, it was possible to integrate technologies such
as the Oculus Rift, the Leap Motion and other accessories
such as joysticks;
• It is possible to reproduce discomfort, fear and
relaxation through virtual reality, even if with less
intensity, enabling an effective treatment. Tests show that
the virtual environment can make people feel similar
emotions experienced in the real world.
As future researches, there could be customizable
levels to give more options to the therapist. In addition, the
tool could support individual treatment using cheaper
devices such as Google Cardboard, where the doctor
would allow the patient to have sessions at home using
virtual reality with a smartphone.
REFERENCES
[1] Enrique Rojas. “Anxiety: how to overcome stress, phobias and
Obsessions” [A ansiedade: como superar o estresse, as fobias e as
obsessões]. Mandarim, São Paulo, 1997.
[2] T.W. Berger, et al. “The impact of neurotechnology on
rehabilitation, biomedical engineering”, IEEE, v.1, pp.157-197,
2008, in press.
[3] Aaron Beck and Gary Emery. Anxiety disorders and phobias: a
cognitive perspective. BasicBooks, USA, 1985.
[4] Valentim Gentil, et al. “Panic, phobias and obsessions” [Pânico,
fobias e obsessões]. Edusp, São Paulo, 1994.
[5] S. Rachman. “Studies in desensitization: flooding, behavior. res. &
therapy”, pp. 1-46, 1966.
[6] T.G. Stampfl and D.J. Levis. “Essentials of implosive therapy: a
learning-theory-based psychodynamic behavioral therapy”, Journal
of Abnormal Psychology, 1967, n. 72, pp. 496-503, doi:
10.1037/h0025238.
[7] Alexandre Cardoso and Edgard Lamounier. “Virtual reality: a
practical approach” [Realidade virtual: uma abordagem prática].
Sine nomine, São Paulo, Oct. 2004.
[8] Wiederhold, B.K. et.al. “The treatment of fear of flying: a
controlled study of imaginal and virtual reality graded exposure
therapy”, IEEE, v.6, pp.218-223. Sept, 2002, in press.
[9] Dayan, E. ARGAMAN: Rapid Deployment Virtual Reality System
for PTSD Rehabilitation. ITRE, pp.34-38. Oct, 2006, in press.
[10] VIRTUALRET, VirtualWare (2007), Basauri, Spain.
[11] Oculus Rift DK1, Oculus VR (2014), Irvine, California.
[12] Unity Technologies, San Francisco, California, US.
[13] Leap Motion Inc., San Francisco, California, US.
[14] Garu Michael Maranell. “Scaling”. Transaction Publishers, 1974.