Exposure has an essential place in the treatment of acrophobia and technology may increase the success of exposure therapies in many ways. We predicted that the integration of acceptance and commitment therapy (ACT) with Virtual Reality (VR) technology would be beneficial in the treatment of acrophobia and would improve clients’ compliance with therapy. This report presents two examples of VR-assisted ACT treatment for acrophobia. The process consists of six sessions (one initial interview and five sessions of interventions) for individual therapy. In the first two sessions, functional behavioral analysis and case formulation with clients were performed and skills to be used during exposure sessions taught. From the second session, application of VR-assisted exposure interventions with ACT principles was started. Results showed a significant improvement for both clients. At the end of the treatment, they were both able to complete the virtual behavioral approach task and presented decreased avoidance strategies and increased value-based behaviors. VR-assisted ACT is promising, especially to facilitate exposure treatments.
1. LeBeau RT, Glenn D, Liao B, Wittchen HU, Beesdo-Baum K, Ollendick T, et al. Specific phobia: a review of DSM-IV specific phobia and preliminary recommendations for DSM-V. Depress Anxiety 2010; 27:148-167.
2. Brandt T, Huppert D. Fear of heights and visual height intolerance. Curr Opin Neurol 2014; 27:111-117.
3. Magee WJ, Eaton WW, Wittchen HU, McGonagle KA, Kessler RC. Agoraphobia, simple phobia, and social phobia in the National Comorbidity Survey. Arch Gen Psychiatry 1996; 53:159- 168.
4. Kapfhammer HP, Fitz W, Huppert D, Grill E, Brandt T. Visual height intolerance and acrophobia: distressing partners for life. J Neurol 2016; 263:1946-1953.
5. Opris D, Pintea S, García-Palacios A, Botella C, Szamoskozi S, David D. Virtual reality exposure therapy in anxiety disorders: a quantitative meta-analysis. Depress Anxiety 2012; 29:85-93.
6. Freeman D, Garety P. Advances in understanding and treating persecutory delusions: a review. Soc Psychiatry Psychiatr Epidemiol 2014; 49:1179-1189.
7. Hone-Blanchet A, Wensing T, Fecteau S. The use of virtual reality in craving assessment and cue-exposure therapy in substance use disorders. Front Hum Neurosci 2014; 8:844.
8. Rothbaum BO, Hodges LF, Ready D, Graap K, Alarcon RD. Virtual reality exposure therapy for Vietnam veterans with posttraumatic stress disorder. J Clin Psychiatry 2001; 62:617-622.
9. Garcia-Palacios A, Botella C, Hoffman H, Fabregat S. Comparing acceptance and refusal rates of virtual reality exposure vs. in vivo exposure by patients with specific phobias. Cyberpsychol Behav 2007; 10:722-724.
10. Bluett EJ, Homan KJ, Morrison KL, Levin ME, Twohig MP. Acceptance and commitment therapy for anxiety and OCD spectrum disorders: an empirical review. J Anxiety Disord 2014; 28:612-624.
11. Wagener AL, Zettle RD. Targeting fear of spiders with control-, acceptance-, and information-based approaches. Psychol Rec 2011; 61:77-91.
12. Bond FW, Hayes SC, Baer RA, Carpenter KM, Guenole N, Orcutt HK, et al. Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance. Behav Ther 2011; 42:676-688.
13. Yavuz F, Ulusoy S, Iskin M, Esen FB, Burhan HS, Karadere ME, et al. Turkish version of acceptance and action questionnaire-II (AAQ-II): a reliability and validity analysis in clinical and non clinical samples. Klinik Psikofarmakol Bulteni 2016; 26:397-408.
14. Kennedy RS, Lane NE, Berbaum KS, Lilienthal MG. Simulator sickness questionnaire: an enhanced method for quantifying simulator sickness. Int J Aviat Psychol 1993; 3:203-220.
15. Kellogg RS, Kennedy RS, Graybiel A. Motion sickness symptomatology of labyrintine defective and normal subjects during zero gravity maneuvers. Aerosp Med 1965; 36:315-318.
16. Marks IM, Mathews AM. Brief standard self-rating for phobic patients. Behav Res Ther 1979; 17:263-267.
17. Schubert T, Friedmann F, Regenbrecht H. The experience of presence: factor analytic insights. Presence 2001; 10:266-281.
18. Schubert TW. The sense of presence in virtual environments: a three-component scale measuring spatial presence, involvement, and realness. J Media Psychol 2003; 15:69-71.
19. Wolpe J. The Practice of Behavior Therapy. Fourth ed., New York: Pergamon Press, 1990.
20. Cohen DC. Comparison of self-report and overt-behavioral procedures for assessing acrophobia. Behav Theraphy 1977; 8:17- 23.
21. Choy Y, Fyer AJ, Lipsitz JD. Treatment of specific phobia in adults. Clin Psychol Rev 2007; 27:266-286.
22. Arroll B, Wallace HB, Mount V, Humm SP, Kingsford DW. A systematic review and meta-analysis of treatments for acrophobia. Med J Aust 2017; 206:263-267.
23. Tart CD, Handelsman PR, Deboer LB, Rosenfield D, Pollack MH, Hofmann SG, et al. Augmentation of exposure therapy with postsession administration of D-cycloserine. J Psychiatr Res 2013; 47:168-174.
24. Polk KL, Schoendorff B, Webster M, Olaz FO. The Essential Guide to the ACT Matrix: A Step-by-Step Approach to Using ACT Matrix Model in Clinical Practice. Oakland, CA: New Harbinger Publications, 2016, 19-40.
25. Price M, Mehta N, Tone EB, Anderson PL. Does engagement with exposure yield better outcomes? Components of presence as a predictor of treatment response for virtual reality exposure therapy for social phobia. J Anxiety Disord 2011; 25:763-770.
26. Kim S, Kim E. The Use of Virtual Reality in Psychiatry: A Review. Soa Chongsonyon Chongsin Uihak 2020; 31:26-32.
27. Miller IT, Wiederhold BK, Miller CS, Wiederhold MD. Assessment and treatment of autism spectrum disorders with virtual reality: a comprehensive research chart. Cyberpsychol Behav Soc Netw 2020; 23:60-65.
28. Etchemendy E, Banos RM, Botella C. Virtual and augmented reality as useful and efficacious tools for the psychological treatment of emotional disorders: In Cipresso P, Serino S (editors). Virtual Reality: Technologies, Medical Applications and Challenges. New York: Nova Publishers, 2015, 31-54.
29. Arch JJ, Eifert GH, Davies C, Plumb Vilardaga JC, Rose RD, Craske MG. Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders. J Consult Clin Psychol 2012; 80:750-765.
30. Craske MG, Niles AN, Burklund LJ, Wolitzky-Taylor KB, Vilardaga JC, Arch JJ, et al. Randomized controlled trial of cognitive behavioral therapy and acceptance and commitment therapy for social phobia: outcomes and moderators. J Consult Clin Psychol 2014; 82:1034-1048.
31. Prudenzi A, Rooney B, Presti G, Lombardo M, Lombardo D, Messina C, et al. Testing the effectiveness of virtual reality as a defusion technique for coping with unwanted thoughts. Virtual Reality 2019; 23:179-185.
32. Meuret AE, Twohig MP, Rosenfield D, Hayes SC, Craske MG. Brief acceptance and commitment therapy and exposure for panic disorder: a pilot study. Cogn Behav Pract 2012; 19:606- 618.
33. Morris E. So long to SUDs – Exposure is not about fear reduction… it’s about new learning and flexibility http:// drericmorris.com/2017/01/13/nosuds/. Accessed December 6, 2019.