Virtual reality:

Using the virtual world to improve

quality of life in the real world
Page L. Anderson, PhD
Barbara O. Rothbaum, PhD
Larry Hodges, PhD

Mental health professionals are increasingly integrating advances in

technology to improve the health of those in their care (American
Psychological Association, 2000). The authors describe the
immersive properties of virtual reality and its importance for clinical
purposes and then review the literature describing current clinical
applications of virtual reality (VR) and research documenting its
efficacy. Virtual reality has been used in the treatment of specific
phobias, posttraumatic stress disorder, eating disorders, and pain
management. (Bulletin of the Menninger Clinic, 65[1], 78–91)

Virtual reality (VR) allows individuals to become active participants

within a computer-generated three-dimensional world. The experi-
ence of users of VR is often described as “getting into” or becoming
immersed in the virtual world. The user is presented with a com-
puter-generated virtual world that changes in a natural way with
head and body motion. The phenomenon of users of VR becoming

This article is based on a presentation at the 22nd Annual Menninger Winter

Psychiatry Conference held March 5–10, 2000, at Park City, Utah. This article was
supported by NIMH Grants #1-R41-MH58493-01, R41-MH60015-01,
and1R41MH58493-01.
Dr. Anderson is a psychologist at Virtually Better, Inc., Decatur, Georgia. Dr.
Rothbaum is an associate professor of psychiatry and director of the Trauma and
Anxiety Recovery Program, Emory University School of Medicine, Atlanta, Georgia.
Dr. Hodges is a computer scientist at the Georgia Institute of Technology, Atlanta.
Correspondence may be sent to Dr. Rothbaum at the Trauma and Anxiety Recovery
Program, Emory University School of Medicine, 1365 Clifton Road, Atlanta, GA
30322; e-mail: brothba@emory.edu. (Copyright © 2001 The Menninger Foundation)
Disclosure Statement: Drs. Rothbaum and Hodges receive research funding and
are entitled to sales royalty from Virtually Better, Inc., which is developing products
related to the research described in this article. In addition, the investigators serve as
consultants to and own equity in Virtually Better, Inc. The terms of this arrangement
have been reviewed and approved by Emory University and Georgia Institute of
Technology in accordance with their conflict of interest policies.

78 Bulletin of the Menninger Clinic

 Virtual reality

immersed in virtual environments provides a potentially powerful

tool for behavioral scientists and other health professionals. VR may
be used to immerse individuals in a virtual environment that activates
relevant fears, which is useful in the treatment of anxiety disorders.
Alternatively, VR may be used to immerse individuals in a virtual en-
vironment that distracts them from the real world, which can be use-
ful in treating individuals undergoing painful medical procedures.
The sense of immersion is achieved by an integration of real-time
computer graphics, body-tracking devices, visual displays, spatial
audio (sound coming from different locations), and other sensory
input. Users are asked to wear what looks like a helmet, which is
called a head-mounted display (HMD). Head-mounted displays con-
sist of computer display screens in front of the eyes of the user, along
with a head-tracking device. The head-tracking device provides head
orientation and/or location orientation information to a computer
that, in turn, shows the user in the HMD images that are consistent
with the direction in which the user is looking within the virtual envi-
ronment. The system may also provide spatial audio information to
the user via stereo headphones.

Anxiety disorders

Emotion-processing theory as applied to anxiety disorders holds that

fear memories include information about stimuli, responses, and
meaning (Foa & Kozak, 1986; Foa, Steketee, & Rothbaum, 1989).
Therapy is aimed at facilitating emotion processing and modifying
the fear structure. Foa and Kozak (1986) suggested that two condi-
tions are required for the reduction of fear. First, the fear memory
must be activated because, as suggested by Lang (1977), if the fear
structure remains in storage unaccessed, it will not be available for
modification. Second, Foa and Kozak proposed that information
must be provided that includes elements “incompatible with some of
those that exist in the fear structure, so that a new memory can be
formed. This new information, which is at once cognitive and affec-
tive, has to be integrated into the evoked information structure for an
emotional change to occur” (p. 22).
Exposure therapy is notoriously good at accessing the fear struc-
ture. Then information incompatible with associations between
stimuli and anxiety responses must be provided during therapy. Sys-
tematic desensitization is a deliberate attempt to provide such infor-
mation by associating relaxation with the feared stimuli. In flooding
and prolonged exposure, confrontation is prolonged in order to
allow response decrements (habituation) to occur, which dissociates

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Anderson et al.

the fear responses from the stimuli. Any method capable of activating
the fear structure and modifying it would be predicted to improve
symptoms of anxiety. Thus virtual reality is a potential tool for the
treatment of anxiety disorders; if an individual becomes immersed in
a feared virtual environment, activation and modification of the fear
structure are possible.
Following is a review of the research examining the efficacy of
VR technology in the treatment of anxiety disorders. Most of the
work to date has focused on treatment of specific phobias. There
also are some data supporting the use of VR exposure therapy for
treatment of combat-related posttraumatic stress disorder among
Vietnam veterans. Other researchers have proposed the use of VR
for treating test anxiety in college students, although to date no em-
pirical studies have been conducted in this area (Knox, Schacht, &
Turner, 1993).

Specific phobia
Case reports: Fear of spiders, heights, and flying. There is a growing
body of literature suggesting that the use of VR in exposure therapy
for specific phobias is effective. A case study of the use of VR in the
successful treatment of spider phobia has been documented (Carlin,
Hoffman, & Weghorst, 1997). A case study conducted in Spain
found that VR exposure therapy for claustrophobia was effective
(Botella et al., 1998). Other work included a study supporting the use
of VR for acrophobia (fear of heights) conducted at Kaiser-Perma-
nente, although analytical data were not presented (Lamson, 1994).
A case study using VR in exposure therapy for treatment of acropho-
bia also has been reported (Rothbaum et al., 1995). The participant
was a 19-year-old undergraduate student with fear of heights, partic-
ularly elevators. VR was used to expose the participant to a virtual
elevator. Therapy sessions were conducted twice weekly, for a total
of five sessions. Decreases from pre- to posttreatment on measures of
anxiety, avoidance, attitude, and distress, as well as a behavioral
avoidance test, indicated that VR was an effective tool for exposure
therapy.
Virtual reality exposure therapy also has been effective in two case
studies of the treatment of fear of flying (Rothbaum, Hodges, Wat-
son, Kessler, & Opdyke, 1996; Smith, Rothbaum, & Hodges, 1999).
The participant in the first case study received treatment for 13 ses-
sions, with 7 sessions devoted to anxiety management training and 6
exposure sessions using a virtual airplane. Results indicated post-
treatment decreases in self-reported anxiety and fearful attitudes to-
ward flying. Furthermore, on a posttreatment flight, the participant’s

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 Virtual reality

anxiety ratings ranged from 0 to 30, on a scale of 0–100. The second

case study involved a shorter course of treatment (four anxiety man-
agement sessions and four exposure sessions using a virtual airplane),
and therapy was conducted according to a treatment manual. As in
the first case study, results showed decreases in self-reported anxiety
and fearful attitudes toward flying, as well as relatively low levels of
self-reported anxiety (15–35) on the posttreatment flight. Further-
more, 6-month follow-up data indicated maintenance of the gains
made in treatment, as measured by self-report questionnaires and by
two subsequent flights.

Controlled outcome data: Fear of heights. The first known con-

trolled study of VR in the treatment of a psychiatric disorder exam-
ined the efficacy of using VR in graded exposure for fear of heights
(Rothbaum et al., 1995). Students (N = 478) from the Georgia In-
stitute of Technology and Georgia State University were screened
for a fear of heights. Of the 20 individuals meeting Diagnostic and
Statistical Manual of Mental Disorders, fourth edition (DSM-IV;
American Psychiatric Association, 1994), criteria for a fear of
heights and randomly assigned to treatment or wait-list, 17 com-
pleted the study.
The pretreatment assessment was conducted in a group format in
separate sessions for the treatment and the wait-list groups. Immedi-
ately following the pretreatment assessment, the first treatment ses-
sion was conducted in which patients were familiarized with the VR
equipment, which displayed a neutral, nonheight setting. They were
allowed to take turns wearing the helmet and were encouraged to in-
teract in VR by looking around a virtual room and “pressing” a but-
ton to turn the lights on and off.
Following the initial group session, participants in the treatment
group received seven weekly individual treatment sessions consisting
of exposure therapy to heights in various virtual environments (vir-
tual footbridges, virtual balcony, virtual elevator). The environments
were presented in the order determined by each subject’s self-rated
hierarchy completed at the preassessment. Patients were encouraged
to spend as much time in each situation as needed for their anxiety to
decrease and were allowed to progress at their own pace. The thera-
pist saw on a computer monitor what the participant saw in the vir-
tual environment and therefore was able to comment appropriately.
To create a greater sense of realism, participants stood on a 4 × 4
raised platform surrounded by a railing, giving the participants rail-
ings to hold and an edge to approach. The virtual environments were
as follows:

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Anderson et al.

Footbridges: Three bridges could be viewed by looking up from a

boat at the bottom of a canyon. The lowest bridge, appearing 7
meters above the water, and the second bridge, appearing 50
meters high, were very solid looking with strong railings. The
highest bridge was suspended 80 meters above the water, with
rope railings and open slats. The two lower bridges and boat
could be viewed from this bridge and helped add to the sensa-
tion of height.
Outdoor balcony: The outdoor open balcony with railings had
four heights: ground floor (0 meters), 2nd floor (6 meters high),
10th floor (30 meters), and 20th floor (60 meters). A street,
buildings, and mountains appeared in the background.
Glass elevator: The glass elevator simulated the elevator at the
Marriott Marquis convention hotel in downtown Atlanta, com-
plete with balconies, artwork, and marble floor. The subject
controlled the movement of the elevator via three “buttons” to
so move up, down, or stop. The elevator moved 49 floors, up to
147 meters at the top, and the floor number appeared in the ele-
vator, from 0 to 48.

Assessments were conducted at pre- and posttreatment, and in-

cluded the Acrophobia Questionnaire (Cohen, 1977) and Attitudes
Towards Heights Questionnaire (Abelson & Curtis, 1989). Results
showed that anxiety, avoidance, and distress decreased significantly
from pre- to postassessment for the VR exposure group but not for
the wait-list control group. Examination of attitude ratings on a se-
mantic differential scale revealed positive attitudes toward heights
for the VR exposure group and negative attitudes toward heights
for the wait-list group. The average anxiety ratings decreased
steadily across sessions, indicating habituation for those participants
in treatment. Furthermore, 7 of the 10 VR exposure treatment
completers exposed themselves to height situations in real life dur-
ing treatment although they were not specifically instructed to do
so. These exposures appeared to be meaningful, including riding 72
floors in a glass elevator and intentionally parking at the edge of the
top floor of a parking deck.
In summary, exposure therapy using VR was very effective in re-
ducing self-reported anxiety and avoidance of heights and improving
attitudes toward heights, whereas the wait-list control group did not
evidence any change. These findings suggested that it is possible for
individuals to become immersed in a virtual environment to the point
that attitudes and behaviors in the real world may be changed as a re-
sult of experiences within a virtual world. Based on these encourag-

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 Virtual reality

ing results, the investigators began developing a virtual airplane to

test its efficacy in comparison to standard exposure therapy for the
treatment of fear of flying.

Controlled outcome data: Fear of flying. The researchers chose to de-

velop and test the efficacy of VR for exposure therapy for fear of fly-
ing (FOF) for several reasons. First, FOF is a significant problem, af-
fecting an estimated 10–25% of the population (Deran & Whitaker,
1980). Also, standard exposure therapy for FOF is inconvenient and
cumbersome for therapists, as well as being prohibitively expensive
for many clients (e.g., going to an airport, reserving time on a station-
ary plane). Furthermore, there are many uncontrollable elements in
standard exposure for FOF (e.g., weather, only one takeoff and land-
ing per flight) that could be controlled in a virtual environment.
Virtual reality exposure (VRE) therapy was compared to standard
exposure (SE) therapy and to a wait-list (WL) control in the treat-
ment of FOF (Rothbaum, Hodges, Smith, Lee, & Price, in press).
Forty-nine patients meeting DSM-IV criteria for either agoraphobia
in which flying was the primary feared situation or specific phobia of
flying were randomly assigned to one of the three conditions. Forty-
five participants, or 15 per group, completed the study.
Treatment consisted of eight individual therapy sessions con-
ducted over 6 weeks, with four sessions of anxiety management
training followed either by exposure to a virtual airplane (VRE) or
exposure to an actual airplane at the airport (SE). Anxiety manage-
ment training sessions were identical for all participants, and in-
cluded breathing relaxation (session 1), educational material about
flying (session 2), cognitive restructuring (sessions 2–3), and thought-
stopping (session 4). Panic exposure also was included in session 4
for participants reporting a history of panic attacks while flying.
Exposure was conducted in sessions 5–8. For participants in the
VRE group, exposure in the virtual airplane included sitting in the
virtual airplane as well as taxiing, taking off, landing, and flying in
both calm and turbulent weather. Exposure sessions were provided
twice weekly in Virtually Better’s office, according to a treatment
manual (Rothbaum, Hodges, & Smith, 1999). During VRE sessions,
each patient wore a head-mounted display with stereo earphones that
provided visual and audio cues and sat in a chair with a woofer
under the seat to add noise and vibrations at appropriate times in the
flight.
For SE sessions, in vivo exposure was conducted at the airport
during sessions 5–8. Due to the time required for travel to and from
the airport, parking, and in vivo exposure, sessions 5 and 6 were

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combined into one extended session, as were sessions 7 and 8. Ses-

sions 5 and 6 were spent at the airport exposing patients to the pre-
flight stimuli (e.g., ticketing, trains, viewing planes, waiting area).
Sessions 7 and 8 were spent on a stationary airplane habituating to
airplane stimuli and conducting imaginal exposure (i.e., imagining
takeoffs, cruising, landing, etc).
Full assessments were conducted at pre- and posttreatment. Each
assessment included self-report measures of anxiety and avoidance of
flying, including the Questionnaire on Attitudes Toward Flying
(QAF; Howard, Murphy, & Clarke, 1983) and the Fear of Flying In-
ventory (FFI; Scott, 1987), as well as patient self-ratings of improve-
ment as measured by the Clinical Global Improvement (CGI) Scale
(Guy, 1976).
More importantly, immediately following the treatment or wait-
list period, all patients were asked to participate in a behavioral
avoidance test consisting of a commercial round-trip flight. The ther-
apist accompanied participants on the flight, and no one was forced
or coerced. Group flights of approximately five participants and one
therapist were scheduled on Delta Airlines between Atlanta and
Houston, approximately 1½ hours per flight. Patients were asked to
pay $164 each for their flights, and Delta agreed to provide full re-
funds if flights were not taken.
The results indicated that each active treatment was superior to
WL and that there were no differences between VRE and SE. For WL
participants, there were no differences between pre- and posttreat-
ment self-report measures of anxiety and avoidance, and only one of
the 15 WL participants completed the graduation flight. In contrast,
participants receiving VRE or SE showed substantial improvement,
as measured by self-report questionnaires, willingness to participate
in the graduation flight, self-report levels of anxiety on the flight, and
self-ratings of improvement. There were no differences between the
two treatments on any measures of improvement. Compared with
WL participants, participants in VRE and SE reported significantly
fewer symptoms of anxiety and avoidance on self-report measures
(QAF and FFI). Furthermore, participants receiving VRE or SE were
approximately 3½ times more likely to take the commercial flight
than were members of the WL control group. During the flight, par-
ticipants receiving either VRE or SE indicated modest levels of anxi-
ety, with no differences between treatment groups. For the departing
flight, the average anxiety ratings (on a scale of 0–100) for VRE and
SE were 33.19 and 33.88, respectively. For the returning flight, the
average anxiety ratings for VRE and SE were 28.73 and 29.77, re-
spectively. Finally, participants who received either VRE or SE said

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 Virtual reality

that they improved significantly more than WL participants. There

were no significant differences between VRE and SE on patient self-
ratings of improvement.
Comparison of posttreatment to the 6-month follow-up data for
the primary outcome measures for the two treatment groups indi-
cated no significant differences, indicating that treated participants
maintained their treatment gains. By the 6-month follow-up, 90% of
treated participants had flown since completing treatment.
These data are important, as they represent the first controlled
study to compare the use of VR in the treatment of a specific pho-
bia to the current standard of care, SE therapy. Every outcome
measure indicated that the use of VR was just as effective as SE
therapy. Interestingly, when WL participants were given the choice
of VR or SE treatment after the waiting period, all but one partici-
pant chose VR.

Posttraumatic stress disorder

The effective use of VR exposure therapy for a Vietnam veteran with
posttraumatic stress disorder (PTSD) has been described in a recent
case study (Rothbaum et al., 1999). Combat-related PTSD is esti-
mated to affect 830,000 veterans (Weiss et al., 1992) and can be a
devastating disorder that is difficult to treat. Although no therapeutic
intervention has been proven to be consistently effective in the treat-
ment of combat-related PTSD, behavioral therapies with an exposure
component have been more effective than most other types of treat-
ment (van Etten & Taylor, 1998), with a handful of studies showing
statistically significant yet relatively small effects using imaginal ex-
posure (Boudewyns & Hyer, 1990; Cooper & Clum, 1989; Keane,
Fairbank, Caddell, & Zimering, 1989). Unfortunately, a significant
number of veterans do not seem to benefit from exposure therapy,
perhaps due to difficulties imagining, visualizing, or describing their
trauma experiences. An uncontrolled treatment development study is
currently underway to evaluate the effectiveness of using VR expo-
sure therapy for Vietnam veterans with combat-related PTSD. This
case study represents the first patient to complete treatment.
The participant was a 50-year-old, married, Caucasian male meet-
ing DSM-IV criteria for PTSD, major depressive disorder, and past al-
cohol abuse. He served as a helicopter pilot in Vietnam approximately
26 years prior to the study. He recently completed a group treatment
at the Atlanta Veterans Affairs Medical Center (VAMC).
Treatment consisted of fourteen 90-minute individual sessions con-
ducted over a 7-week period. Session 1 was spent gathering informa-
tion, explaining the rationale for treatment, and teaching breathing re-

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Anderson et al.

laxation. During sessions 2–3, the patient wore the head-mounted dis-
play and was familiarized with two virtual environments:

Virtual jungle clearing: The participant moves through a jungle

clearing and swamp. The therapist can control various visual ef-
fects, including muzzle flashes, helicopters flying overhead, and
low-lying fog. The therapist also can control audio effects, in-
cluding recordings of jungle sounds, gunfire, helicopters, mine
explosions, and men yelling “Move out! Move out!”
Virtual helicopter: The participant is a passenger on a Huey heli-
copter. The participant sees the backs of the heads of the pilot
and copilot and the instrument controls. The view through the
helicopter side door includes other helicopters flying past,
clouds, and the terrain below, including rice paddies, jungle, and
a river.

During sessions 4–5, the patient was immersed in the virtual envi-
ronments and asked to describe in detail the memories triggered by
the scenes. Sessions 6–14 were spent immersing the patient in the vir-
tual environments plus imaginal exposure to his most traumatic
memories (determined prior to treatment). During all sessions, the
therapist communicated with the patient through a microphone,
prompting him to stay with the traumatic memories until habituation
occurred. The therapist also tried to match the virtual environment to
the memories as described out loud by the patient: for example, mak-
ing the helicopter land and take off as the patient described these
events. At the end of each session, the patient practiced breathing re-
laxation and discussed the session with the therapist.
Full assessments were conducted at pretreatment, posttreatment,
3-month follow-up, and 6-month follow-up. Assessments included
clinician-rated and self-report measures of PTSD: Clinician-Adminis-
tered PTSD Scale (CAPS; Blake et al., 1992); Impact of Events Scale
(IES; Horowitz, Wilner, & Alvarez, 1979); Beck Depression Inven-
tory (BDI; Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961); and
State-Trait Anger Expression Inventory (STAXI; Spielberger, Jacobs,
Russell, & Crane, 1983).
Results indicated posttreatment improvement on all measures of
PTSD and maintenance of these gains at 6-month follow-up. On var-
ious measures of PTSD-related symptoms, the decrease between pre-
and postassessment and pre- and 6-month follow-up, respectively,
were 34% and 26% (CAPS), 45% and 100% (IES), 19% and 43%
(BDI), 63% and 63% (STAXI-State), and 21% and 14% (STAXI-
Trait). Qualitatively, these decreases in scores represent a change

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 Virtual reality

from “severe” to “moderate/threshold” range of PTSD as measured

by the CAPS, from “severe” to “moderate” on the BDI, and a mean-
ingful shift from “severely angry” on the STAXI. The 6-month fol-
low-up of 0 on the IES obviously indicates no PTSD symptoms re-
lated to the trauma rated, which at first seems impossible to believe.
However, the IES asks that a specific memory be rated for instrusion
and avoidance. The specific memory rated by the patient was also the
memory that was addressed in treatment. This finding suggests that
VR exposure therapy was quite effective for that particular memory,
although the participant clearly continues to struggle with PTSD-re-
lated symptoms.
In summary, the use of VR for exposure therapy in the treatment
of a variety of anxiety disorders, including specific phobia and PTSD,
seems promising. In addition to efficacy, VR offers other advantages,
including preserving confidentiality for the patient, increasing control
of the exposure for the therapist, and increasing convenience for both
the therapist and the patient. Of course, there are disadvantages as
well. Some patients may not be able to immerse themselves in virtual
environments, and currently there are no data regarding who consti-
tutes a good candidate for VR rather than in vivo exposure. Further-
more, as with any computer program, there are occasional program
“glitches.” Finally, the cost of VR has in the past been prohibitively
expensive for the typical therapist in private practice. However, the
price of using VR continues to drop and the ease of use of VR contin-
ues to improve with advancements in technology. The fear of heights
study (Rothbaum et al., 1995) was conducted using a computer and
hardware system that cost around $150,000 and that required a
graduate student in computer science to operate. The fear of flying
study (Rothbaum et al., 2000) was conducted using a regular PC and
hardware that cost around $20,000 and that even a computer-
illiterate therapist could operate. Currently, a PC-based system that
can be used for treatment of fear of flying is available for about
$5,000.

Eating disorders

Researchers in Italy, led by Giuseppe Riva, are conducting innovative

work integrating VR with experientially based cognitive therapy for
eating disorders (Riva, Bacchetta, Baruffi, Rinaldi, & Molinari,
1998). In a recent case study, VR was used in the inpatient treatment
of a 22-year-old university student diagnosed with anorexia nervosa
(Riva, Bacchetta, Baruffi, Rinaldi, & Molinari, 1999). Over the
course of 8 weeks, VR was used in conjunction with cognitive ther-

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Anderson et al.

apy to address maladaptive beliefs about eating, temptation exposure

with response prevention to address disordered eating behavior, and
body image work to address distorted perceptions of weight and size.
Differences from pre- to postassessment indicated increase in body
awareness, decrease in body dissatisfaction, and increase in motiva-
tion for treatment. Future work in the use of VR is much desired for
such difficult-to-treat disorders.

Pain management

Whereas the use of VR exposure therapy for anxiety disorders and

eating disorders capitalizes on immersing patients in the virtual
world, virtual reality for pain management benefits patients by dis-
tracting them from the real world. Cognitive-behavioral techniques
have long been used in conjunction with pharmacology for pain man-
agement. A recent case study examined the use of VR for pain man-
agement for two adolescents receiving burn-wound care (Hoffman,
Doctor, Patterson, Carrougher, & Furness, 2000). Using a single-
subject design, two patients received opioid analgesia in conjunction
with distraction. Distraction included playing Nintendo or entering a
virtual kitchen, in which the patients could pick up appliances with a
cyberhand or touch the body of a spider. Both adolescents received
both types of distraction using a single-subject design, with one pa-
tient playing the video game first and the other patient entering the
virtual kitchen first. Both patients reported dramatic decreases in
pain ratings, anxiety, and amount of time spent thinking about pain
during burn care while in the virtual kitchen as compared to playing
Nintendo. The patients also reported higher levels of immersion in
VR as compared to video, and the level of immersion in VR increased
across burn-care sessions. These data are particularly important be-
cause immersion is presumed to be a key feature of VR, although it
has rarely been tested in a systematic manner.

Future directions

Virtual reality is a promising tool for mental health professionals.

There are now controlled studies showing its efficacy in the treatment
of specific phobias, including fear of heights and fear of flying, as
well as promising case reports for the treatment of posttraumatic
stress disorder, eating disorders, and pain management. Clearly,
larger scale controlled studies comparing VR to the current standard
of care are needed, as well as studies that examine the benefit of inte-
grating VR to current comprehensive treatment programs.

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 Virtual reality

Future research also is warranted to tease out the mechanism by

which VR is effective in the treatment of anxiety disorders. For exam-
ple, it seems likely that VR activates the fear structure for individuals
with phobias via immersion; however, controlled research investigat-
ing the level of immersion in VR and its relationship to treatment
outcome is sorely limited. In addition to activating the fear structure,
it also is possible that VR aids in the modification of the fear struc-
ture; for example, by providing the opportunity to pair an incompat-
ible behavioral response (e.g., relaxation) with the feared stimulus.
Furthermore, VR may aid in the modification of the fear structure by
helping patients become more aware of and thereby modify maladap-
tive and inaccurate beliefs. If so, then VR may bolster the effective-
ness of cognitive therapies for other psychiatric disorders, such as de-
pression and social phobia. Research identifying good candidates for
VR therapy also is needed; individual differences in immersion is one
of many potential variables to be explored.
An early article reviewing the use of VR for psychotherapy sug-
gested that a virtual social environment has great promise for ad-
dressing problematic interpersonal behavior (Glantz, Durlach, Bar-
nett, & Aviles, 1993). Technological difficulties modeling people has
left this area underexplored, although advances in the integration of
video with virtual environments may make virtual social environ-
ments the next avenue for many behavioral researchers. Virtual social
environments have tremendous applications, potentially making be-
havioral role plays more real and more effective. For example,
teenagers may practice negotiation of condom use in a virtual envi-
ronment as a part of STD/HIV/teen pregnancy prevention. A virtual
audience has recently been created and will soon be tested in the
treatment of fear of public speaking.
Finally, as the cost and ease of use of VR continues to improve, it
will be important for training programs in psychology, behavioral
science, and medicine to incorporate VR into their respective curric-
ula. Medical training programs have been the leaders in this area:
One research program uses virtual reality in the training for laparo-
scopic and endoscopic surgical techniques (Yagel, Stredney, & Wiet,
1996). Training programs in behavioral science, psychiatry, psychol-
ogy and public health also should encourage students to consider the
ways in which VR and other advances in technology can help us bet-
ter serve our patients and public.

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